Documentation, Litigation Prevention, NCLEX Review
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76 Terms
What is the best practice to reduce litigation risk in nursing?
Accurate, timely, and complete documentation.
NCLEX Answer for reducing litigation risk
Document accurately, objectively, and promptly.
Legal rule about documentation
If it wasn't documented, legally it may be viewed as though it wasn't done.
What should nurses document?
Assessments, interventions, patient responses, and communication.
When should documentation be completed?
As soon as possible after providing care.
How should documentation be written?
Using factual and objective language.
Should a nurse ever alter or falsify documentation?
No.
Documentation example
Patient reports pain 8/10. Morphine 2 mg IV administered as ordered. Pain decreased to 3/10 after 30 minutes.
Another way to reduce litigation risk
Follow the standard of care.
How can nurses follow the standard of care?
Follow policies and procedures.
How can nurses follow the standard of care?
Use evidence-based practice.
How can nurses follow the standard of care?
Perform required assessments.
How can nurses follow the standard of care?
Follow the rights of medication administration.
Another way to reduce litigation risk
Communicate effectively.
Examples of effective communication
Notify the provider of significant changes.
Examples of effective communication
Report critical laboratory values promptly.
Examples of effective communication
Use SBAR or approved handoff tools.
Another way to reduce litigation risk
Know your scope of practice.
Scope of practice means
Do not perform procedures you are not trained or authorized to perform.
What should a nurse do if unsure about performing a procedure?
Ask for help.
Another way to reduce litigation risk
Obtain proper informed consent.
Nursing responsibility regarding informed consent
Verify consent has been obtained before procedures when required.
If a patient has unanswered questions before a procedure
Notify the provider.
Who explains procedures, risks, benefits, and alternatives?
The healthcare provider performing the procedure.
Who verifies informed consent?
The nurse.
Another way to reduce litigation risk
Maintain patient safety.
Examples of maintaining patient safety
Prevent falls.
Examples of maintaining patient safety
Follow infection-control practices.
Examples of maintaining patient safety
Verify patient identity before medications or procedures.
Examples of maintaining patient safety
Monitor for complications.
Another way to reduce litigation risk
Maintain professional boundaries.
Professional boundary responsibility
Protect patient confidentiality under HIPAA.
Professional boundary responsibility
Avoid inappropriate relationships with patients.
Professional boundary responsibility
Maintain professional communication.
NCLEX Question: Which nursing action is most effective in reducing malpractice claims?
Completing documentation accurately and promptly.
Why is accurate documentation important?
It creates a legal record of the care provided.
Why is developing friendships with patients incorrect?
Nurses must maintain professional boundaries.
Why is delegating all tasks to assistive personnel incorrect?
The nurse remains accountable for delegated tasks.
Why is explaining surgical risks incorrect?
Explaining risks is the provider's responsibility.
Memory Trick
DOCUMENT.
D in DOCUMENT
Document promptly.
O in DOCUMENT
Observe carefully.
C in DOCUMENT
Communicate changes.
U in DOCUMENT
Understand your scope of practice.
M in DOCUMENT
Maintain standards of care.
E in DOCUMENT
Educate patients.
N in DOCUMENT
Never falsify records.
T in DOCUMENT
Tell the provider about significant changes.
NCLEX Pearl
When asked what best protects a nurse from legal action, the answer is often: Follow the standard of care and document everything accurately and promptly.
Advance Directive
A legal document stating a patient's wishes about future healthcare if they cannot make decisions.
Purpose of an advance directive
Allows patients to make healthcare decisions ahead of time.
Purpose of an advance directive
Helps patients maintain control over medical care.
Purpose of an advance directive
Reduces uncertainty for family members and healthcare providers.
Living Will
Specifies what treatments the patient wants or refuses.
Examples included in a Living Will
CPR, mechanical ventilation, tube feeding, dialysis, and life-support treatments.
Memory Trick for Living Will
Living Will = What the patient wants.
Durable Power of Attorney for Healthcare
Names the person who will make healthcare decisions if the patient cannot.
Memory Trick for Durable Power of Attorney
Power of Attorney = Who decides.
Requirements for an advance directive
Patient must be an adult or legally authorized, have decision-making capacity, and sign voluntarily.
Nurse's responsibility regarding advance directives
Ask about them during admission.
Nurse's responsibility regarding advance directives
Place a copy in the medical record if available.
Nurse's responsibility regarding advance directives
Respect the patient's wishes.
Nurse's responsibility regarding advance directives
Educate the patient if requested.
Nurse's responsibility regarding advance directives
Notify the provider if the patient has questions.
The nurse should NOT pressure a patient
To complete an advance directive.
The nurse should NOT make healthcare decisions
For a competent patient.
Difference between an Advance Directive and a DNR
An advance directive is a legal document; a DNR is a medical order.
A DNR applies only when
The patient's heart or breathing stops.
Does a DNR mean "Do Not Treat"?
No.
Can a competent patient refuse treatment?
Yes, even if refusal may result in death.
Can family automatically override an advance directive?
No.
Scenario: Patient says, "If I can't recover, I don't want machines keeping me alive."
Encourage discussion with the provider and documentation in a Living Will.
Scenario: Unconscious patient arrives with a valid advance directive
Follow the patient's documented wishes and facility policy.
Scenario: Daughter wants to make decisions for an unconscious patient
She may do so only if legally designated as the Durable Power of Attorney for Healthcare.
Scenario: Patient with a DNR develops pneumonia
Treat the pneumonia unless the patient refused that treatment. DNR only prevents CPR.
Final NCLEX Tip
Support competent patients' informed decisions, follow the standard of care, maintain confidentiality, and document everything accurately.