215 doc. and legal

  1. full legal responsibilty for nursing actins rest with who
    the nurse
  2. nurse practice act =
    • tells you what you can and cannot do as an RN
    • May differ by state
  3. If you operate outside of your scope of practice what can happen.
    • lose you license.
    • cannot give meds without an order
  4. The process by which an educational program is evaluated and recognized as having met certain standards =
  5. what are the voluntary agencies that accredit schools
    • NLNAC
    • AACN
  6. what determines entry-level competence
  7. what is the next step after licensure
    • certification
    • validates specialty knowledge, experience and clinical judgement
  8. Torts are
    wrongs commited bu person against another person or his property
  9. nursing commit assult when
    thy threaten a pt
  10. nurses commits battery when
    • they do something to someone that they do not want
    • ie. pt doesnt want injection and nurse gives it anyway
  11. negligence =
    • unintentional tort
    • performing act that a reasonable prudent person would not do.
    • Not doing something a reasonable prudent person would do
    • ie.
  12. Malpractice =
    unintentional tort by a professional
  13. 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
  14. Deposition =
    formal interview of an expert witness or anyone with relevant information
  15. what is the liability of the student
    they are responsible for their own actions
  16. If you are working as a nursing assistant you may only perfom services
    in your own job description
  17. 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
  18. what are some examples of ermitted disclosures of health information
    • tracking disease outbreaks
    • infection control
    • info for investigation
    • child abuse
    • deceased individuals
  19. #1 and #2 purposes of client records
    • Communication between disciplines
    • Diagnostic and therapeutic orders
  20. *****what should you chart*****
    • what you see
    • hear
    • feel
    • smell
    • measure
    • count
  21. documentation characteristics should be
    complete, accurate, concise, current, factual
  22. avoid descriptive words like...... for charting
    good, average, normal
  23. what do you document in regards to the provider
    • the date
    • time
    • reason
    • and response to any communication with the provider
  24. only record what you see & hear do not assume
  25. what time do you use in charting
    military time
  26. when do you document as far as time is concerned
    immediately following the care given
  27. charting format =
    • žMake sure you have the correct chartž 
    • Use proper grammar & spellingž 
    • Use only standard terminology ž 
    • Use only approved abbreviationsž 
    • Utilize hospital approved forms only and always use ink (black)ž 
    • 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
  28. can you add a later entry in charting
  29. ISBARR =
    • identification
    • situation
    • background
    • assessment
    • recommendation/request
    • read back
Card Set
215 doc. and legal
215 doc. and legal