Legal Implications in Nursing and Informatics

Scope of Nursing Practice (2)

1. defines nursing —> role, scope, function of nurses in practice

2. reflects profession values

Standards of Nursing Care (what? derived from 4 things?)

1. knowledge & skill ordinarily possessed by nurses

2. derived from healthcare laws, best practice, evidenced-based knowledge, & citizen advocacy groups

Who sets the standards?

1. The Joint Commission (TJC)

2. Centers for Medicaid & Medicare Services (CMS)

• evacuates quality & appropriateness of care

• set by multiple regulating bodies (including state & federal laws)

Patient Self-Determination Act (PSDA est. 1990)

requires health institutions to provide written info to patients regarding their rights to decision-making about their care. includes:

• right to refuse treatment

• right to formulate advanced directive

Benefits 

1. patient autonomy

2. improved end of life care

3. reduce conflicts when patients are unable to make decisions

Patient Protection & Affordable Care Act (PPACA est. 2010)

1. consumer rights & protections

2. affordable healthcare coverage (reduced cost)

3. increased access

4. quality care that meets patient needs (improved efficiency)

5. Cost Containment - slow increase of healthcare costs

Health Insurance Portability & Accountability Act (HIPPA est. 1996)

1. national standard

2. all patient info is confidential

3. protects info from ALL unauthorized readers

4. minimum necessary - requirement of disclosure or reguests about health info

5. reduction in healthcare fraud

6. portability of health insurance

Paperwork cannot have identifiers such as:

1. birthdate

2. social security

3. room #

4. medical record #

5. unique identifying data

Nurse Practice Act

State laws intended to:

• protect citizens

• make nurses accountable

• assure care is best practice & within scope/standards

Licensure - may investigate, revoke, or suspend

1. Application

2. Renewal Cycles based on state (every 2 years on April 30th/July 31st)

3. Nurse Licensure Compact

Informed Consent

1. Explanation of procedure

2. Names & Qualifications of people involved

3. Description of serious harm or death (anticipated pain/discomfort)

4. Alternative therapies + risk of doing nothing

5. Right to refuse - without losing other care

6. Right to refuse even after procedure begins

Negligence

falls below generally accepted standard of care of a reasonably prudent person

Malpractice

• type of negligence

• person held liable must be a professional

Standard of Proof

what a reasonably prudent nurse would do

• under similar circumstances

• in geographical area in which alleged breach occurred

Documentation should include:

1. pertinent client data

2. decisions & interventions

3. client response & impact of intervention

Correcting Errors Best Practice

narrative entry in medical record statement indicating error has been made and is being corrected (Florida State Board of Governors)

• draw single name through error then date & initial

• use computer “time stamp”

Audit Trail 

demonstrates any manipulation or changing of records