Foundations Exam Review: Ethics, Legal, Documentation, and Patient Care

Vocabulary flashcards generated from nursing foundation exam review materials covering ethics, legal responsibilities, informed consent, advance directives, Texas Safe Harbor, mandatory reporting, and documentation standards.

Autonomy

Right to make personal decisions, even if not in the person's best interest.

Beneficence

Action that promotes good for others.

Fidelity

Fulfillment of promises.

Justice

Fairness in care and resource use.

Nonmaleficence

Commitment to do no harm.

Veracity

Commitment to tell the truth.

Advocacy

Support/defend health, wellness, safety, wishes, rights, privacy.

Responsibility

Respect obligations and follow through.

Accountability

Answer for your actions.

Confidentiality

Protect privacy.

Ethical Dilemma

A situation where scientific data alone cannot solve it, moral imperatives conflict, and the answer has a profound effect on the client/situation.

Moral Distress

Situation where the nurse identifies the ethically correct action, but actions taken are different from what the nurse believes is correct.

Compassion Fatigue

Emotional exhaustion tied to repeated exposure to suffering.

Professional Negligence

Failure to act reasonably/prudently.

Five Elements to Prove Negligence

Duty, Breach, Foreseeability, Causation, and Harm (D-B-F-C-H), all $5$ of which must be present for malpractice to be proven.

Standards of Care

Directives that define/direct expected nursing care, instructing nurses not to practice beyond competency and to use the chain of command when an assignment feels unsafe.

Informed Consent - Provider Role

Explains purpose, procedure, participants, risks/harm/pain/discomfort, alternatives, refusal option/consequences, and obtains informed consent.

Informed Consent - Client Role

Gives consent voluntarily, must be competent/legal age or represented, must receive enough information to understand, and may withdraw consent.

Informed Consent - Nurse Role

Witnesses signature, ensures provider gave information and client appears to understand/competent, obtains signature, notifies provider for unanswered questions, and documents communication/interpreter use.

Living Will

An advance directive detailing specific treatment wishes.

Durable Power of Attorney / Health Care Proxy

An advance directive providing decision-making support by designating an agent to make healthcare choices.

Texas Safe Harbor

A $5$-step process (Request before assignment, Notify supervisor, Document safety concerns, Continue if not serious risk, Peer review) invoked for unsafe staffing, skills beyond competency, scope issues, or lack of essential equipment/resources.

Mandatory Reporting

Legal requirements to report child abuse, elder abuse, adult violence, and communicable diseases, which vary by state.

Factual Documentation

Quality charting trait containing objective observations/measurements plus subjective patient statements while avoiding judgments.

Accurate Documentation

Quality charting trait requiring exact measurements, concise wording, correct spelling, approved abbreviations, and date/time.

Current Documentation

Quality charting trait requiring prompt entries to prevent unsafe care caused by delays.

Organized Documentation

Quality charting trait following a logical sequence: assessment -> intervention -> response.

Complete Documentation

Quality charting trait detailing essential nursing care and patient response, expanding detail when condition changes.

F-A-C-O-C

Mnemonic for documentation quality traits: Factual, Accurate, Current, Organized, Complete.