Documentation, Legal & Ethical Responsibilities

Section 2

When documenting abnormal findings, “exceptions ___ _______”

Get attention

What should the nurse do if they were unable to document notes in the EMR immediately?

Chart as a late entry

When documenting, what should nurses avoid?

Altering/addending prior notes

When should vital rounds on a patient begin to be timed?

When the patient is admitted to the floor

Nice nurses:

Avoid legal trouble!

What counts as intentional torts?

Assault/Battery, false imprisonment, invasion of privacy, libel

What counts as unintentional torts?

Negligence, malpractice, abandonment, deception

What is an example of libel?

Making rude comments or gossiping about a patient or coworker

What is the exception to abandoment in medical care?

The Good Samaritan Law

What is an example of the Good Samaritan Law?

A nurse stopping at an accident and leaving when EMS arrives.

A terminal patient is refusing food and water. What should the nurse do?

Keep mucous membranes moist with ice chips, lip balm, or sprays

What tasks can be delegated to UAP?

Bathing, feeding, dressing, transferring

What tasks cannot be delegated to UAP?

Unstable patients, evaluations, assessments, teaching

The patient has limited english, but the nurse has given instructions in English. What does the nurse need to do?

Have patient demonstrate to evaluate understanding.

What is guided imagery?

Technique of visualizing positive place/images or scanrious in their mind

What does the Patient Self-Determination Act (PSDA) require the nurse to ask the patient?

Always ask if the patient has advanced directives

If the patient has no advanced directives and care team is unable to construct one, what is the directive?

Full life saving measures, full code

Where should a patient’s advanced directive be documented?

In the patient’s chart

Does a advanced directive need to be notarized?

No

How can an advanced directive be constructed?

With 2 healthcare witness not in direct care of the patient, and not the charge nurse

What advanced directive is Durable Power of Attornery (DPOA)?

Assigns another person to make medical decisions

What is a living will?

The desired medical care one wants if they are unable to communicate their wishes

What is an AND?

Allow natural death

What is a DNI?

Do not intubate

What is a chemical code?

Medications only, no CPR or defibs

What to do when assessing an unconscious patient?

Assess for danger, pt response, then ABC’s (airway, breathing, circulation)

The patient is losing consciousness and has a DNR. What are your next steps as a nurse?

Assess pt response, ABC’s, and notify provider

When using therapeutic communication, you should never ask:

“Why?” (To avoid judgment)

What is SBAR?

Structure used to give report/updates about a patient to the provider, during hand-offs, or when being admitted or transferred

What is the structure of report during hand off?

Situation, background, assessment, and recommendation

How should the nurse treat emancipated minors?

As though they are adults