Case Study Essay on Professional and Documentation Failures of a Nurse

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Assignment: Case Study Essay
ExHUCL1301: Assignment: Case Study Essay
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Assignment: Case Study Essay
Introduction
The essay will discuss different professional failures conducted by an employee in the given case
study. It will provide with different scenarios where the medical practitioner has conducted
documentation failure and unprofessional conduct. The essay will provide with examples and
evidence from the case study.
There are various evidences in the case study which depicts for unprofessional conduct in
relation to documentation committed by the nurse. The first example is where the nurse failed to
document a postoperative assessment for the patient. Continuously the nurse was unable to
record vital signs q4h as ordered for the patient, failed to document a pain assessment for the
patient and failed to complete a thorough assessment and document of the patient (CARNA and
Alberta RN Magazine, 2016, Pp.13-14). The nurse also was unable to complete a pre-operative
checklist of a patient who ate breakfast and was not supposed to have anything.
There are various departments that have been impacted by the unprofessional and medical
misconduct of the nurse. The departments identified in the case study are the Finance
Department, Dietary Department, Medical Records, Information Management and Health Care
Department. The Finance Department has been impacted as the nurse failed to check for the
order made for the patient's medications form the hospital pharmacy. The nurse also failed in
adequately documenting the patient’s admission and history for records of the bills and omission
in inserting the ordered NG tube (CARNA and Alberta RN Magazine, 2016, Pp.13-14). The
finance department was impacted as proper records and documentation were not made according
to the actual expenses. The Department of Medical Records is also affected in the process of
keeping up regular and adequate records of the medical requirements and specific records of the
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Assignment: Case Study Essay
medical notes kept. As the nurse failed to perform various assessments and keep up with the
medical information of the patients the medical records departments have been impacted.
The Information and Management department of the hospital has also been impacted by the
faults and omissions conducted by the nurse. The nurse failed to notify the doctors about feeding
a patient with breakfast who was supposed to be on NPO. This created issues and complications
in the surgery and medical treatments of the patients. The information management has been
impacted as differences in surgery, and medical outcomes have been witnessed due to the fault of
the nurse (Neumann, Davis & Littles, 2019, para 7, pp.431). The Health Care department has
also been impacted as the nurse failed to provide with adequate care to the patient and perform
proper medical assessments and trials of the patients. The nurse was unable to provide with
vitals, assessments of IV and urostomy sites, pain assessments and administration of the Fragmin
which impacted on the Health Care department that is responsible for maintaining high standards
and levels of safety for the patients. The Pharmacy department is also affected as the nurse
failed to keep with a record for the patient’s medication orders and also failed in developing an
adequate assessment of the patients’ blood glucose levels to provide with necessary medications
(Urden, Stacy & Lough, 2017). Further, she failed to complete pain assessments and records
which hampered the department of Pharmacy to keep track of medicines ordered.
The nurse is required to undergo various assessments and tests in order to pass and testify the
skills and knowledge of the nurse. The nurse will withstand the analysis of clinical nursing skills
which will verify and prove the skills of the nurse according to the required levels of her
profession. It will also testify to the necessary level of knowledge in her field, and according to
the duties and roles, she is expected to follow in her job title. The nurse will also undergo
assessment of necessary medication and documentation which will enable the human resources
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Assignment: Case Study Essay
and the medical professional evaluation team to analyse her capabilities and skills (CARNA and
Alberta RN Magazine, 2016, Pp.13-14). The necessary medication administration will judge the
administrative skills and abilities of the nurse regarding the nursing processes and duties. The
nurse is not allowed to practice pending medical clearance, and she is also restricted to work
under supervised practice. The burse is to provide with two satisfactory performance evaluations
in order to satisfy the administrators and the evaluators. She is to provide with ongoing proof for
the medical fitness to continue her practice as the nurse in the hospital (CARNA and Alberta RN
Magazine, 2016, Pp.13-14).
Conclusion
It has been identified that it is the responsibility of the healthcare practitioners to work in an
ethical and professional manner. In the above case study, it has been evaluated that the nurse
performed various mistakes and issues which led to differences in the performance for the other
departments in the hospital.
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Assignment: Case Study Essay
References
CARNA and Alberta RN Magazine, (2016). Publications ordered by Hearing Tribunals.
Volume 72 No 2. Pp.13-14.
Neumann, J. L., Davis, L., & Littles, K. (2019). Ethical Issues Related to New Cellular
Therapies and the IMPACT on Nursing Practice. Biology of Blood and Marrow
Transplantation, Vol.25. no.3, pp.431.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2017). Critical Care Nursing-E-Book:
Diagnosis and Management. Elsevier Health Sciences.
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