HUCL1301 Essay: Analyzing Documentation Errors in a Healthcare Setting

This essay analyzes a case study focusing on documentation errors within a healthcare setting. The student identifies five key documentation mistakes made by a nurse, including failures to document vital signs, preoperative checklists, CVC line procedures, blood glucose levels, and patient history. The essay thoroughly examines the impact of these errors on patient care, highlighting how they affect various healthcare professionals, such as general practitioners, surgeons, and specialists. The author emphasizes that inaccurate or missing information can lead to medical errors, negatively affecting the quality of patient care and treatment outcomes. The essay concludes by reiterating the importance of accurate documentation in maintaining patient safety and supporting effective healthcare practices.

Running head: TRANSCRIBING MEDICAL ORDERS
TRANSCRIBING MEDICAL ORDERS
Name of the student:
Name of the university:
Author note:

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TRANSCRIBING MEDICAL ORDERS
Introduction:
In the healthcare organization, each and every healthcare staff have some professional
boundaries which plays an important role in providing quality care to the patient. One of the
professional boundaries for the registered nurse is to conduct the documentation properly
(Ashton, 2016). This essay mainly focusses on the 5 documentation error observed in the case
study and its effect on the other healthcare department and patient’s care.
Discussion:
Documentation is referred as the critical vehicle used to convey essential medical
information about the diagnosis, treatment and the outcome of the patient (Lavin, Harper & Barr,
2015). From the case study, it can be identified that the nurse have done several mistakes related
to documentation. 1st documentation mistake observed in the case study is that the nurse had
failed in documenting the vital signs every four hour as ordered. 2nd documentation mistake is
conducted by the nurse while a patient is going for operation. The nurse failed to conduct the
pre-operative checklist which includes the information regarding the diet such as the patient had
breakfast or not. 3rd documentation error had been observed during the dressing of the CVC line,
the nurse failed to document that the jugular CVC line has been removed or not and flushed it
with the wrong solution at the wrong time. 4th documentation error identified in the case study is
the inappropriate documentation of the blood glucose level (BGL) of the patient, which can be
considered as the barrier in providing quality care of the patient. 5th documentation mistake
observed in the case study is failed documentation of the patient’s history and admission.
Documentation errors is referred to as the documentation of the false information or the
missing information. Documentation errors of the nurses can lead to medical errors due to the

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passing of these false information or incomplete information to the other healthcare staff
(Ostrovsky et al., 2016). These can have negative impact on the quality care of the patient. The
documentation errors mentioned above have impacted the other healthcare professional in the
treatment and diagnosis of the patient. For example the 1st documentation errors can have
impacted the general practitioner, who is handling the patient, as vital signs helps in the detecting
and the monitoring of the medical problems of the patient (Mok, Wang & Liaw, 2015). 2nd
documentation error might have negative impact on the surgeon during the operation as the
preoperative care is extremely important for the better recovery of the patient (Liddle, 2018). 3rd
documentation error that is error during the CVC line is considered to have impacted the
department of surgery which deals with the severe illness. 4th documentation error during the
measurement of BGl, which can have impact on the specialist who is taking care of the patient
and the 5th documentation error can have impact on the other healthcare staff and the doctors who
are going to treat the patient.
Conclusion:
From the above essay, it can be concluded that the documentation error hampers the
quality care of the patient and it also have impact on the different healthcare specialist and staff
in the treatment of the patient. In the essay, 5 documentation error observed in the case study and
its effect on the other healthcare department and staff are also described.

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References:
Ashton, K. S. (2016). Teaching nursing students about terminating professional relationships,
boundaries, and social media. Nurse education today, 37, 170-172.
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(6).
Liddle, C. (2018). An overview of the principles of preoperative care. Nursing standard (Royal
College of Nursing (Great Britain): 1987).
Mok, W. Q., Wang, W., & Liaw, S. Y. (2015). Vital signs monitoring to detect patient
deterioration: An integrative literature review. International Journal of Nursing Practice,
21, 91-98.
Ostrovsky, Y., Buttaro, T. M., Diamond, J., & Hayes, J. (2016). Technology and dynamic
pathways: how to improve nursing care, documentation, and efficiency. Iproceedings,
2(1), e31.