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full legal responsibilty for nursing actins rest with who
the nurse
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nurse practice act =
- tells you what you can and cannot do as an RN
- May differ by state
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If you operate outside of your scope of practice what can happen.
- lose you license.
- cannot give meds without an order
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The process by which an educational program is evaluated and recognized as having met certain standards =
accreditation
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what are the voluntary agencies that accredit schools
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what determines entry-level competence
Licensure
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what is the next step after licensure
- certification
- validates specialty knowledge, experience and clinical judgement
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Torts are
wrongs commited bu person against another person or his property
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nursing commit assult when
thy threaten a pt
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nurses commits battery when
- they do something to someone that they do not want
- ie. pt doesnt want injection and nurse gives it anyway
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negligence =
- unintentional tort
- performing act that a reasonable prudent person would not do.
- Not doing something a reasonable prudent person would do
- ie.
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Malpractice =
unintentional tort by a professional
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6 elements must be established to prove that malpractice or negligence occured
- Duty-obligation to use due care
- Breach of duty-failure to meet SOC
- Foreseeability- link between nurse’s act & injury suffered
- Causation-failure to meet SOC actually caused injury
- Harm or injury- physical, emotional, financial
- Damages-awarded if malpractice caused the injury
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Deposition =
formal interview of an expert witness or anyone with relevant information
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what is the liability of the student
they are responsible for their own actions
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If you are working as a nursing assistant you may only perfom services
in your own job description
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what are the HIPPA pt. rights
- see and copy their health record
- update their health record
- to get a list disclosures made for purposes other than treatment, payment and healthcare operations
- choose how to receive health information
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what are some examples of ermitted disclosures of health information
- tracking disease outbreaks
- infection control
- info for investigation
- child abuse
- deceased individuals
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#1 and #2 purposes of client records
- Communication between disciplines
- Diagnostic and therapeutic orders
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*****what should you chart*****
- what you see
- hear
- feel
- smell
- measure
- count
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documentation characteristics should be
complete, accurate, concise, current, factual
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avoid descriptive words like...... for charting
good, average, normal
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what do you document in regards to the provider
- the date
- time
- reason
- and response to any communication with the provider
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only record what you see & hear do not assume
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what time do you use in charting
military time
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when do you document as far as time is concerned
immediately following the care given
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charting format =
- 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
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can you add a later entry in charting
yes
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ISBARR =
- identification
- situation
- background
- assessment
- recommendation/request
- read back
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