Legal Issues and Nursing Documentation – Flashcards

1. Discuss the importance of the Nurse Practice Act 2. Define Standards of Care 3. Describe intentional and unintentional torts as related to patient's rights 4. Discuss the importance of HIPPA as it relates to patient confidentiality 5. List guidelines for effective documentation 6. Describe the purposes of patient records 7. Compare and contrast different methods of documentation 8. Describe the purpose of the following nursing documentation formats: nursing assessment, nursing care plan, progress notes, flow sheets, medication administration records 9. Describes the method for documenting nursing interventions completely, accurately, currently, concisely and factually 10. Describe the nurse's role in communicating with other healthcare professionals by reporting and conferring 11. Utilize the ISBARR method of communication with healthcare professionals

• Full legal responsibility & accountability for nursing actions rest with the nurse Need to be aware of laws that regulate nursing • To ensure the nurse's decisions and actions are consistent with current legal principles • Protect the nurse from liability

• Most important law affecting nursing practice • May differ by state • Protects the public by defining the scope of nursing practice • Nurses must practice within these guidelines • "Delineation of specific functions and procedures included in the practice of nursing" (ANA) • *Practicing beyond your scope is a violation of the Nurse Practice Act*

• The process by which an educational program is evaluated & recognized as having met certain standards • Legal/Required- must be state accredited, sets the minimum standards of education (KBN) • Voluntary- voluntary agencies (NLNAC, AACN) accredit schools when they meet certain criteria

• *Legal document which permits a person to practice nursing (NCLEX-RN exam)* • Determines entry-level competence

• Validates specialty knowledge, experience and clinical judgment • American Association of Critical-Care nurses • Certified pediatric nurse

*wrong committed by person against another person or his property* • Intentional or unintentional • Subject to action in civil court

restraining an alert/oriented client in order to administer a medication

forcing someone to remain in the hospital (if they are of sound mind) - can only tell them they will be leaving AMA, Against medical advise which means insurance won't pay

assault, battery, fraud, invasion of privacy, false imprisonment

unintentional tort: • Performing act that a reasonable prudent person would not do • Not doing something a reasonable prudent person would do

• Negligence by a professional

• A relationship existed between the client and the care giver • The care giver acted negligently (did not act in a way a prudent care giver would- SOC) • The negligent behavior caused the actual injury • The injury led to specific damages • Physical pain • Mental anguish • Lost wages/earning capacity

• Skills and learning commonly possessed by members of a profession • Legal guidelines for nursing practice

• i.e.: Labor and delivery nurses

formal interview of an expert witness or anyone with relevant info. Nurse as a defendant, fact witness or expert witness

• Student nurses are responsible for their actions • Legal responsibility to prepare for clinical • Must notify clinical instructor if you feel unprepared to carry out a procedure/task • Instructors must provide reasonable and prudent supervision • Notify your instructor right away of changes in patient status/condition • If you are working as a nursing assistant- you may only perform services in your job description

• Passed by Congress in 1996, enacted in 2002 under the Bush Administration • PHI- protected health information • Patient's Rights: See and copy their health record Update their health record To get a list of disclosures made for purposes other than treatment, payment & healthcare operations Choose how to receive health information

Public health activities Tracking of disease outbreaks Infection control Law and judicial proceedings Information necessary for investigation and/or prosecution of a crime i.e.- child abuse or domestic abuse cases Deceased individuals Funeral arrangements Organ donation Coroner cases

Computers Copiers Cell phones Fax machines Pagers can result in fines, imprisonment or penalties

It is the written or typed, legal record of all pertinent interactions with the patient Promotes effective communication between all members of the healthcare team Demonstrates quality of client care

1. *Communication between disciplines* 2. Diagnostic and therapeutic orders 3. Care planning 4. Quality review- to ensure standards of care are being followed 5. Research 6. Education 7. Legal documentation 8. Reimbursement 9. Historical documentation- provides record of medical hx

Complete, accurate, concise, current, factual *DO chart what you*: See Hear Feel Smell Measure Count NOT what you: Suppose Infer Conclude Assume

• Use descriptions; avoid words such as "good", "average", "normal" • Document nursing interventions and patient's response • Chart decimal points correctly • Charting correct information- use client's own words when possible • Avoid stereotypes and derogatory terms • Do NOT chart for someone else or vice versa • Document all medical visits/consultations • Document the date, time, reason and response to any communication with the provider.

Document date and time of each entry Do NOT chart Nursing Care, Observations, or Medications in Advance Do NOT wait until the end of the shift to chart Use military time to avoid confusion between AM and PM

Make sure you have the correct chart Use proper grammar & spelling Use only standard terminology Use only approved abbreviations Utilize hospital approved forms only and always use ink (black) Do not leave blank spaces or blank pages- write N/A on blank spaces at the end of the page or fill in with a line or large X

Include client's name and ID# on each page- e.g. address or graph stamp. Sign & title each entry & place full signature where required: First initial, last name, title Do not write in margins- if necessary to attach an addendum, do so chronologically with date/time addendum made. Can add a "late entry" if needed

1. Make neat, legible entries, utilizing correct spelling & proper language 2. Do not cover information with tape that obliterates 3. Do not use correction fluid- White Out or Liquid Paper -to make corrections. Correct errors in charting according to hospital policy- single line, initial, date, time, and reason

*Repeat back to verify accuracy* Must be cosigned within agency time frame Record order on client's chart Date & Time Record T.O., full name title of physician Sign with nurses' name and title EX: Morphine 2mg IM q4hours prn pain T.O. Dr. Conner/T. Freeman, R.N

Used during an emergency Order given directly by a physician or NP to a RN or pharmacist Order must be repeated and verified Recorded in the client's record with date & time Nurse documents the order as follows: EX: Lasix 40mg IVP STAT V.O. Dr. Miller/T. Freeman, RN The MD or NP must sign the order after the emergency

Nursing Admission Assessment/Database Kardex- allergies, diet, activity, IV, tests Nursing Care Plans Progress notes (PIE, SOAP, DAR) Discharge /transfer documents Flowsheets Graphic-wts, VS Intake/Output MAR-Medication Administration Record Wound assessment

Types of Report 1. Change of Shift Report Written Face to face Bedside rounds 2. Telephone/Telemedicine Reports 3. Transfer & Discharge Reports 4. To Family Members/Significant Others

I= Identify Self, patient S= situation What is the situation you are calling about B= background Diagnosis, date of admission, VS, mental status, IV, lab results A= assessment What you think is going on R= recommendation What you need from the physician R= Read back

Consultations (specialists) Referrals (PT, OT, hospice, home health, social services)

Agency record of an accident or unusual occurrence Means of identifying risks Not used for disciplinary action Not a part of the patient's record Examples: Patient falls Visitor falls Medication error

• Strictly adhere to hospital's confidentiality & data security policies • Consider patient confidentiality when positioning the monitor screen • Do not trade computer passwords • Do not leave the terminal unattended once you've logged on & log off when documentation is completed

Altered Records immediately raise suspicion Never remove documents from a medical record- missing or incomplete records suggest that you have something to hide If it is not documented- it was never done!

*In this section of your narrative entry you will provide data about the situation. * Such as the date and time, what happened, vital signs, pain status, etc. EXAMPLE: 8/11/08 7:45 am Entered Jane's room and found her on the floor next to her bed. Jane stated "I don't remember what happened, but I think I feel down, please help me up." Resident reported significant pain on the right side of her chest when attempting to move. Small amount of blood identified on right side of head just above her right ear.

*What did you do?* What action did you take in response to the data already described? A narrative entry is never complete without an explanation of the action you take. Imagine if the narrative entry example stopped after the data entered above; the entry would not paint a complete picture of the situation and how you handled it. Remember...if it wasn't documented, it wasn't done. EXAMPLE: Instructed resident to remain on the floor and radioed for assistance from another caregiver. Caregiver John Doe entered the room and I asked him to call 9-1-1. I remained with resident, told her the paramedics would arrive soon.

*How did the resident respond to the actions you took?* You may need to enter two responses, one immediately and then another as a follow up. EXAMPLE: 8/11/08 8:15 am Paramedics arrived and transported resident to St. Mary's Hospital. 8/11/08 1:30 pm Spoke to doctor James Doe from St. Mary's Hospital. She informed me that Jane has two broken ribs and will be staying in the hospital overnight.

▪ Introduce yourself and your role in the patient's care ▪ State the unit you are calling from when speaking with a physician over the phone

▪ Specify the patient's name and current condition or situation ▪ Explain what has happened to trigger this conversation

▪ State the admission date of the patient, his or her diagnosis, and pertinent medical history ▪ Give a brief synopsis of what's been done so far (e.g., lab test)

▪ Give a summary of the patient's condition or situation ▪ Explain what you think the problem is or say, "I'm not sure what the problem is, but the patient is deteriorating" ▪ Expand upon your statement with specific signs and symptoms

▪ Explain what you would like to see done (e.g., lab tests, treatments, or "I need you to see the patient now") ▪ State any new treatments or changes ordered (e.g., monitoring and frequency or when to renotify the physician if there is no improvement in the patient)

The benefits of the SOAP format are that it can be tailored to any type of study or study visit and that, if done properly, will satisfy both the medical record needs for the continuing care of the client and the source documentation requirements for the study. Below is a broad definition of the components of the SOAP format and then three examples of how it might be used in specific scenarios.

*the client's report of how he or she has been doing since the last visit, and this includes the current visit. * Subjective comments made by client may range from no complaints ("I feel great") to specific current complaints ("I've had a headache for 3 days") to complaints that took place in the interim but have resolved ("3 weeks ago I had diarrhea for a couple of days"). For an infant's record, the subjective component would include the mother's (or caretaker's) observations. Again, these may range from no complaints ("The baby is happy and healthy") to a specific current complaint ("the baby's been fussy lately") to a complaint that has resolved ("the baby had a nappy rash, but it's all better now"). The client should be asked directed questions about any complaints - current or reportedly resolved -- and ask appropriate follow-up questions and document all responses. Reports of compliance with specific treatment regimens - whether study-related or not - should also be included here: "How much of your study medication did you take since your last visit? Did you miss any doses? Why?" or "At the last visit, you were given antibiotics for pneumonia. Do you have any pills left?"

*straightforward and includes vital signs * (temperature, blood pressure, pulse, respiration), documentation of the physical examination that was done, and results of laboratory or other studies that may be done during the course of this visit. For a client with no complaints, the physical exam may be limited to meet study-specific needs. For a client with a complaint, an appropriate focused physical exam should be completed in addition to or instead of the study-specific exam.

For this component, *the clinician pulls together the subjective information gathered during the interview with the client and the objective findings of the physical exam (and, possibly, laboratory or other study results) and consolidates them into a short assessment*: EX: "This is a 26-year old woman here for a routine HPTN microbicide study visit; there are no clinical problems today" or "This is a 22-year old pregnant woman, 26 weeks gestation by physical exam, here for a non-study visit due to chief complaint of increased nausea for 1 week and vomiting for 2 days" or "This is a 46-year old HIV-infected man here for routine HPTN study visit with increased fatigue and pallor; blood smear is positive for malaria."

The *plan should include anything that will be done as a consequence of the assessment and could include: * o The collection of study-specific labs or special studies o The collection of labs or special studies to address an acute complaint o Intention to admit to the hospital o Study-specific medications dispensed (name of drug, amount dispensed and dosing instructions) o Non-study medications prescribed or dispensed for a specific acute or chronic complaint (name of drug, amount dispensed and dosing instructions) o Follow-up instructions to the client (for example: "return to the clinic if this problem does not resolve") o Date of next appointment

*This is a simplified approach to focusing on the client's problems, interventions, and evaluations. * This documentation format omits the care plan but utilizes flowsheets and progress notes. The progress notes utilize nursing diagnoses as the problem. A number of different problems (with interventions and response) may be recorded, numbered sequentially, and each problem is evaluated at least one time during each shift.

(problem, intervention, evaluation) Date: 2/1/2008 Time: 1320 • Progress Notes: • P—Risk of aspiration secondary to • Decreased level of consciousness. • I—Head of bed elevated to 45 degrees while eating and for one hour after eating. Liquids thickened and fluids given with straw. Dr. B. Jones notified. Ativan DC'd.----T. Freeman, RN Date: 2/1/2008 Time: 1500 E—No aspiration. Client alert and responsive. -------------------------T. Freeman, RN *PIE charting focuses on the nursing process, but it omits the planning for care that is part of more comprehensive documentation formats, so this may pose aproblem for less-experienced nurses, and it may result in different approaches to problem solving and inconsistencies of care.*