HUCL1301 Case Study Essay: Fundamental Medical Orders & Documentation

This essay, focusing on the HUCL1301 module, examines unprofessional conduct in medical documentation within healthcare settings. It identifies five specific examples of such conduct, including failure to make timely entries, deceitful documentation, and inaccurate recording of information. The essay then details the impact of these actions on various professionals and departments, such as nurses, physicians, surgeons, hospital administration, and the financial department, highlighting potential consequences like medical errors, legal issues, and financial losses. The analysis emphasizes the importance of accurate documentation in maintaining professional responsibility, patient safety, and the overall integrity of healthcare practices, supported by references to relevant research and literature. The assignment aims to provide a comprehensive understanding of the critical role of documentation in healthcare and the repercussions of unprofessional conduct.

Running head: FUNDAMENTAL OF MEDICAL ORDERS
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Fundamental of Medical Orders
Name
Institution

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Introduction
Awareness of how to document accurately during healthcare delivery can lead to positive
health outcomes. Documentation errors can be disastrous both to the patient and the healthcare
provider. Besides, healthcare providers may be at risk of malpractice lawsuits due to improper
documentation (Bijani et al., 2016). The following paper explains five examples of
unprofessional conduct in relation to documentation. Besides, a list of professionals/departments
who could be impacted by these acts of unprofessional conduct is also provided.
Examples of Unprofessional Conduct in Relation to Documentation committed by the
Nurse
Failure to make a medical entry and date and time of intervention is unprofessional
conduct related to documentation. This occurs when nurses perform interventions and fail to
record in the patient charts. Another improper conduct is the failure to document an intervention
on time (Bijani et al., 2016). Healthcare providers may delay updating the records despite
performing an intervention at the right time. Also, providing deceitful and untrue documentation
is unprofessional. This occurs when false information is included in the documentation. For
instance, in the case where the nurse failed to document implies that a colleague updated the
records on his behalf, which would indicate the colleague performed the intervention. Also,
failing to note the errors made during an intervention is unethical and leads to deceitful
documentation.
Another unprofessional conduct concerning documentation is making incomplete
documentation or missing out on some details. For instance, healthcare providers may forget to
document every assessment or intervention they performed to patients (Bijani et al., 2016).
Moreover, making inaccurate documentation is an example of unprofessional conduct. For

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instance, when a nurse fails to appropriately and precisely document about intervention as well
as recording the wrong details leads to inaccurate documentation.
Professionals/ Departments who could be impacted by Acts of Unprofessional Conduct in
Relation to Documentation
Unprofessional conduct concerning documentation may impact several professionals and
departments in the healthcare setting. Examples of professionals and departments affected by
acts of improper conduct in relation to documentation include nurses, physicians, surgeons, the
administration of the hospital, and the financial department (Lavin, Harper & Barr, 2015). The
healthcare providers highlighted, in this case, interact with patients during health delivery.
Evidence supporting how nurses could be impacted by unprofessional conduct in relation
to documentation includes the delivery of inappropriate care. To illustrate this, nurses may be
misguided by the documentation errors made by other nurses or healthcare providers. For
instance, a nurse may perform a medication error due to incorrect documentation by a colleague.
Another impact on nurses is the possibility of getting sued by patients (Lavin, Harper & Barr,
2015). Unprofessional conduct in relation to documentation by nurses may lead to medical
errors, which in turn into lawsuits against them. Patients who get injured or experiences other
consequences of medical errors due to improper documentation may take legal action against
nurses.
Physicians are also affected by acts of unprofessional conduct concerning documentation.
For instance, physicians who make documentation errors every now, and they may lose their
license due to incompetence and failure to adhere to set standards. Furthermore, physicians get
impacted by making the wrong diagnosis of patients’ conditions based on incorrect and deceitful
documentation by other healthcare providers.

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Surgeons get impacted by documentation errors; for instance, they may interfere with
patient safety. This occurs when nurses fail to document complete and accurate pre-operative
assessment, which misleads the surgeons into performing wrong procedures, for instance,
operating the wrong patient (Lavin, Harper & Barr, 2015). Also, surgeons may be forced to
postpone surgical operations for patients due to delayed documentation, missed entries, or
incomplete documentation.
The hospital administration also gets impacted by unprofessional conduct during
documentation. For instance, the hospital administration loses revenues due to documentation
errors. This occurs when patients stop seeking health services from the hospital due to medical
errors that may arise due to documentation. Another impact is the loss of reimbursements from
the government and other organizations which interfere with the provision of healthcare
resources. The financial department is also impacted, whereby documentation errors may lead to
inappropriate billing, resulting in charges of fraud (Lavin, Harper & Barr, 2015). Another
impact on the financial department is access to insufficient funds, which hinders the department
from purchasing certain healthcare items. This occurs when specific interventions by healthcare
providers to patients are not documented hence leading to loss of revenue.
Conclusion
Acts of unprofessional conduct may occur during documentation. For instance, failure to
make entries, failure to document about an in intervention on time, provision of deceitful and
untrue documentation is unprofessional, incomplete documentation, as well as inaccurate
documentation, are acts of unprofessional conduct. The professionals and departments impacted
by the unprofessional conduct include nurses, physicians, surgeons, the administration of the
hospital, and the financial department.

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References
Bijani, M., Sadeghzadeh, M., Jeihooni, A. K., & Hannan, K. S. (2016). Factors influencing poor
nursing documentation from the perspective of nursing staff. International Journal of
Medical Research & Health Sciences, 5(11), 717-718.
Lavin, M. A., Harper, E., & Barr, N. (2015). Health information technology, patient safety, and
professional nursing care documentation in acute care settings. Online J Issues
Nurs, 20(2).