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