University Essay: Unprofessional Conduct in Healthcare Documentation

This essay delves into the realm of unprofessional conduct within healthcare settings, specifically focusing on the critical role of nurses' documentation. The author highlights various documentation errors, such as failures in post-operative assessments, missed vital sign recordings, incomplete pre-operative checklists, inadequate blood glucose level documentation, and omissions in patient history. The essay meticulously outlines how these errors can negatively impact patient outcomes, hinder the work of other healthcare professionals, and potentially compromise the quality of care. The discussion emphasizes the importance of adhering to professional standards and the Nursing and Midwifery Board of Australia's guidelines to ensure patient safety and effective healthcare delivery. The essay concludes by reiterating the detrimental consequences of unprofessional conduct in healthcare.

Running head: UNPROFESSIONAL CONDUCT IN HEALTHCARE
UNPROFESSIONAL CONDUCT IN HEALTHCARE
Name of Student:
Name of University:
Author’s Note:

1UNPROFESSIONAL CONDUCT IN HEALTHCARE
Introduction:
Professional conduct of the nurse is demarcated as the professional values, beliefs and
perception of the nurse based on which they provide treatment to the patient suffering from
illness or injury (Cowin et al., 2019). Nursing and Midwifery Board of Australia has formulated
certain codes and conduct of registered nurse which aid nurse and healthcare staff in providing
appropriate and safe care to the patient. This essay focusses on the examples of certain
unprofessional conduct of nurse in relation to the documentation performed by the nurse and its
impact on the different and professional/department.
Discussion:
According to the Nursing and Midwifery Board of Australia (2019), proper
documentation and assessment of the patient is vital to deliver efficient care.. Documentation in
clinical setting is vital to deliver enhanced health outcomes of the patient and a single error
during documentation can lead to negative health outcomes or further health deterioration.
1. First unprofessional conduct of the nurse which is observed by analyzing the case study is
documentation error of the member of a patient before operation. The member has failed to
perform appropriate documentation associated with post-operative assessment of a patient at
proper time. Apart from that, the member also failed to notify other member in the next shift
that the patient has missed the dose of Septra. As in the case of patient mentioned above, the
members failed to perform proper documentation of the post-operative assessment of the
patient, the possibility of recover of the patient is seem to reduce as well as the chances of
further health deterioration of the patient also increase (de la Torre & Carr, 2015) As this
incident is directly related to the post-operative assessment of the patient, it might impact

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negatively to the other health care staff or nurse working on the next shift or the general
practitioner taking care of the patient.
2. Another documentation error observed by the CARNA member is during the care of the
same patient. On the next day the patient had failed to document the vital signs of Q4h as
recommended and along with that also failed to document the result of the pain assessment
and complete assessment of the patient.
As the member has avoided the documentation of the vital signs of Q4h as
recommended, it can possess negative impact on the acute operative care setting and on the
healthcare specialist taking care of the patient (Stevenson-Ågren et al., 2015).
3. Third documentation error observed by the member during the assessment of the patient
going for surgery. The member has failed to perform the proper documentation of pre-
operative assessment and has failed to complete the checklist that whether the patient had
his/her breakfast or not.
As mentioned above, the patient is going for a surgery, unprofessional conduct of the
member might hinder the surgical procedure of the patient (Reyes et al., 2017).
From the above discussion, it can be stated that, unprofessional conduct of the
CARNA member can possess negative to the surgeon and might create complications for
them during surgery.
4. Fourth documentation error observed by the member is during the assessment of the blood
glucose of the patient. The member has failed to document the blood glucose level of the
patient and along with that failed to document the medication order and thorough assessment
of the Patient.

3UNPROFESSIONAL CONDUCT IN HEALTHCARE
It can possess negative impact on the general practitioner who is providing care to the
patient due to the lack of proper knowledge regarding the blood glucose level and medication
orders of the patient (Sieber et al., 2017)
5. Last documentation error observed by the member is the unprofessional conduct of the nurse
during the documentation of the previous clinical history of the patient. The member has
failed to document the adequate history and admissions of the patient.
As the unprofessional conduct of the nurse is related to the previous clinical history of
the patient. It can possess negative impact on the general healthcare professionals who is
going to take care of the patient (Baumann, Baker & Elshaug, 2018). Due to this the
healthcare professionals cannot provide required care to the patient.
Conclusion:
From the above essay, it can be stated that, professional conduct of the nurse if not
followed in the healthcare setting can lead to further health deterioration of the patient. In the
above assignment, five different unprofessional conduct associated to the proper documentation
performed by nurse in the healthcare setting has been listed in the discussion. It is observed that
the unprofessional conduct of the nurses possess negative impact on the healthcare professional
and department.

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Reference:
Baumann, L. A., Baker, J., & Elshaug, A. G. (2018). The impact of electronic health record
systems on clinical documentation times: A systematic review. Health Policy, 122(8),
827-836.
Cowin, L. S., Riley, T. K., Heiler, J., & Gregory, L. R. (2019). The relevance of nurses and
midwives code of conduct in Australia. International nursing review, 66(3), 320-328.
de la Torre, R., & Carr, J. M. (2015). U.S. Patent Application No. 14/670,172.
Nursing and Midwifery Board of Australia. (2019). Nursing and Midwifery Board of Australia -
Professional standards. Retrieved 7 October 2019, from
http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-
standards.aspx
Reyes, C., Greenbaum, A., Porto, C., & Russell, J. C. (2017). Implementation of a clinical
documentation improvement curriculum improves quality metrics and hospital charges in
an academic surgery department. Journal of the American College of Surgeons, 224(3),
301-309.
Sieber, J., Flacke, F., Link, M., Haug, C., & Freckmann, G. (2017). Improved glycemic control
in a patient group performing 7-point profile self-monitoring of blood glucose and
intensive data documentation: an open-label, multicenter, observational study. Diabetes
Therapy, 8(5), 1079-1085.
Stevenson-Ågren, J., Israelsson, J., Nilsson, G., Petersson, G., & Bath, P. (2015). Documentation
of vital signs in electronic records: the development of workarounds. In ISHIMR 2015:

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17th International Symposium for Health Information Management Research, York, UK,
June 25-26, 2015.