Legal/Ethical Aspects of Nursing and Documentation
The study of information processing
INFORMATICS
Being responsible for ones own actions
ACCOUNTABILITY
Best defense in the event of legal claims associated with nursing care
ACCURATE DOCUMENTATION
One who defends or pleads a cause or issue on behalf of another
ADVOCATE
Documentation that is considered a safety measure in preventing errors from poor communication during "Hand off" or "handover" interactions
SBAR
Meanings for SBAR or SBARR
SITUATION, BACKGROUND, ASSESSMENT, RECOMENDATION (READ BACK)
Defines acts whose performance is required, permitted, or prohibited
STANDARDS OF CARE
What is SOAPIER?
SUBJECTIVE, OBJECTIVE, ASSESSMENT, PLANNING, IMPLENTATION, EVALUATION, REASSESS
Charting divided into sections or blocks that include sections like admission information, physicians orders,progress notes, history and etc.
TRADITIONAL (BLOCK) CHART
A decision that the court renders based on the facts of the case
VERDICT
Legal record that is used to meet the many demands of the health, accreditation, medical insurance, and legal systems
CHART (health care record)
Recording the interventions carried out to meet the patient's needs
CHARTING
Nurses chart complete physical assessments, observations, vital signs, intravenous site and rate, and other data at the beginning of each shift
CHARTING BY EXCEPTION
Multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high risk, high volume, high cost types of cases
CLINICAL PATHWAY
Wheeled cart that houses point-of-care systems
COMPUTER ON WHEELS
Accumulated health information
DATABASE
Out-of-court, under oath statement of a witness
DEPOSITION
Refers to full disclosure of the facts the patient needs to make an intelligent decision before any invasive treatment or procedure is performed
DOCTRINE OF INFORMED CONSENT
Medical record that can be exchanged from one facility to another
ELECTRONIC HEALTH RECORD
Medical record that can only be exchanged within a facility
ELECTRONIC MEDICAL RECORD
Situations that do not have a clear right or wrong answer
ETHICAL DILEMMAS
Refers to values that influence a person's behavior and the individuals feelings and beliefs about what is right or wrong
ETHICS
Process of self evaluation that helps gain insight into personal values
VALUE CLARIFICATION
System used by some facilities to consolidate patient orders and care needs in a centralized concise way
KARDEX (RAND)
These prescribe proper behavior in society and sanction acceptable behavior and prohibit unacceptable behavior
LAWS
Legal responsibility
LIABILITY
Legally responsible
LIABLE
Professional negligence
MALPRACTICE
Recording of patient care in descriptive form can be computerized and non-computerized in abbreviated story form instead of outline style
NARRATIVE CHARTING
Absence of due care
NEGLIGENCE
A classified system of technical or scientific names and terminology
NOMENCLATURE
This means to do no harm
NONMALEFICENCE
Plan that outlines the proposed nursing care based on the nursing assessment and nursing diagnoses to provide continuity of care
NURSING CARE PLAN
An extension of the EHR that allows patients to input their own information into an electronic database
PERSONAL HEALTH RECORD
Bedside systems used for input of information
POINT-OF-CARE
Active, inactive, potential, and resolved problems serves as the index for chart documentation
PROBLEM LIST
SOAPE or SOAPIER are what type of documentation?
PROBLEM ORIENTED
Organized according to the scientific problem-solving system or method; principal sections are database, problem list, care plan, and progress notes
PROBLEM-ORIENTED MEDICAL RECORD (POMR)
Personal beliefs about the worth of an object, an idea, a custom, or an attitude
VALUES