Ethics, Legal and Documentation

Nursing documentation should be which of the following? Select all that apply. 1. Accurate 2. Nonjudgmental 3. Specific 4. Opinionated 5. Dispensable

1,2,3

The nurse's obligations in ethical decisions include which roles? Select all that apply. 1. Being a patient advocate 2. Being involved in institutional ethics committees 3. Improving one's own ethical decision making 4. Functioning as a team member 5. Debating a patient's ethical decisions

1,2,3,4

Which are document expectations? 1. Detailed 2. Complete 3. Bias free 4. Readable 5. Accurate 6. Extensive 7. Defensible

1,2,3,5,7

What factors contribute to a person's ethical beliefs? Select all that apply. 1. Career 2. Values 3. Attitudes 4. Beliefs 5. Morals

2,3,4,5

Ethical Principles: Fidelity (Fathfulness)

Duty to keep promise

Moral Distress in Nursing

Knowing what is appropriate, but being unable to act on it.

Types of Charting

Narrative PIE Charting by Exception Focus SOAP(IER)

Moral Uncertainty

Unease Questioning Unclear course of action

Ethical Principles: Veracity

duty to tell the truth

Ethical Principles: Justice

obligation to be fair

Which are outcomes of effective nursing documentation? Select all that apply. 1. Safe nursing practice 2. Continuity of client care 3. Efficient time management 4. Cost-conscious nursing care 5. Effective nurse-client relationships

1,2,3

Nurses' Professional Values-AACN essential

Altruism Autonomy Human Dignity Integrity Social Justice

Flow Sheets

Graphic record Intake and output Medication administration record Skin assessment record

Malpractice

a professional person has failed to act in a reasonable and prudent manner

Which consequentialist theory requires a risk-benefit analysis? 1. Deontology 2. Utilitarianism 3. Whistleblowing 4. Conflict of universal principles

2

The charge nurse is helping another nurse care for a client whose condition is deteriorating. Without knowing the client, which portions of the health record should the charge nurse access first in this emergency situation? Select all that apply. 1. Discharge plan 2. Graphic data and vital signs 3. History and physical 4. Advance directive 5. Family contact information

2,4

The MORAL Decision - Making Model

M—Massage the dilemma O—Outline options R—Review criteria and resolve A—Affirm position and act L—Look backdecision making

Moral Development

Process of learning difference between right and wrong Begins in childhood and continues throughout life Moral development theories provide frameworks to view and clarify moral and ethical dilemmas

Moral Distress

Right course of action is known Unable to complete due to Institutionalized obstacles

Ethical Principles: Autonomy

person's right to choose and ability to act on that choice

What is the purpose of documentation? 1. Tracking the nurses on each shift 2. Improving the facility's care quality 3. Facilitating communication among team members 4. Sharing data with insurance companies 5. Allowing nurses to summarize physician findings 6. Creating legal report of care delivery 7. Providing consistent care from shift to shift

2,3,6,7

The client has right-sided hemiplegia as a result of a stroke (brain attack) and wants a cup of hot coffee. Even though the client is insistent, the nurse does not permit her to drink the coffee unsupervised. This nurse is using the ethical principle of 1. Autonomy 2. Fidelity 3. Nonmaleficence 4. Justice

3

Annie is planning to move to another state. She looks at the Board of Nursing website to explore that state's regulations for registered nurses. What is this an example of? Make the Connection. Drag and drop proper term that is best exemplified by each case scenario. 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Emergency Medical Treatment and Active Labor Act (EMTALA) 3. Patient Self-Determination Act (PSDA) 4. Americans With Disabilities Act (ADA) 5. Good Samaritan Law 6. American Nurses Association Code of Ethics 7. Patient Care Partnership 8. Standard of Practice 9. Nurse Practice Acts 10. Scope of Practice

9

Health Record System - Source-Oriented

Disciplines document in separate sections of the chart Contains a variety of sections (e.g., admission, H&P, diagnostic, graphic, nurses' notes, progress notes, lab, rehab, DC plan, etc.) Data scattered; may lead to fragmentation

Unacceptable Abbreviations -"DO NOT USE"

MS, MSO4, MgSO4 (Morphine Sulfae or Magnesium Sulfate) u or ug (for microgram) T.I.W. (Three times a week) __x D (Number of days or doses) A.S.. A.D., A.U. (Left ear, right ear, or both ears) O.S., O.D., O.U. (Left eye, right eye, or both eyes)

State Laws Guiding Nursing Practice

Mandatory reporting laws (communicable disease & abuse) Good Samaritan Laws (differ by state) Nurse practice Acts (credentialing, licensing, discipline) Other: Institutional policies and procedures Nursing codes of ethics Patient care partnership ANA Nurses' Bill of Rights

Calvin is considering a transfer to the interventional radiology department. He's unfamiliar with the expectations in the nursing role within that department and looks for practice guidelines. What is this an example of? Make the Connection. Drag and drop proper term that is best exemplified by each case scenario. 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Emergency Medical Treatment and Active Labor Act (EMTALA) 3. Patient Self-Determination Act (PSDA) 4. Americans With Disabilities Act (ADA) 5. Good Samaritan Law 6. American Nurses Association Code of Ethics 7. Patient Care Partnership 8. Standard of Practice 9. Nurse Practice Acts 10. Scope of Practice

8

Factors in Ethical Decision Making

Developmental Stage Values Attitudes Beliefs

Focused Charting

Focuses on client concerns and strengths DAR format: - Data-assessment phase: Subjective and objective information 16 yr received on unit at 1400 from PACU post appendectomy. Pt with down syndrome. Morphine PCA initiated.. Pt unable to use PCA ... - Action-planning and implementing phase: Will discuss pt status with parents and adjust plan of care accordingly - Response-evaluation phase: Met with parents. Who report that pt has significant developmental delays. . .

Charting by Exception (CBE)

Incorporates flow sheets, standards of nursing care, bedside chart forms Agencies develop standards of nursing practice Documentation according to standards involves a check mark Exceptions to standards described in narrative form on nurses' notes Advantages: - Reduce the amount spent on documentation - Reduce repetitive charting of routine care Disadvantages: - Inadvertent omissions

Which must a nurse remember when accessing articles on the Internet related to nursing practice? 1. The article may not be reliable. 2. The article will be factual if it is on the Internet. 3. The article usually has an anonymous author. 4. If an article has been up-voted many times, it is probably a good resource.

1

Telephone/Verbal Orders

*AVOID* if possible!! Know the state nursing board's position on who can give and accept Know the agency policy Write the order down on physician's order forms Read the order back to the primary care provider Question the primary care provider about any order that is ambiguous Have the primary care provider verbally acknowledge the read-back order Must be countersigned by the primary care provider within a time described by agency Note: - AVOID PHONE ORDERS. - AVOID VERBAL ORDERS. ONLY IN AN EMERGENCY!!!!

12/23/21 0200 Received patient from the E.D. BP 85/62, HR 118, RR 24, temp 102°F, sats 94%. Arouses to verbal stimuli but drifts back to sleep. Normal saline infusing in left arm via 20-gauge IV catheter at 200 mL/hr. Urinary catheter draining scant dark amber urine. O2 at 4 L/min via nasal cannula. Lungs with coarse crackles bilaterally. Loose cough present, unable to expectorate secretions. Nasotracheal suctioning x 1 for thick green sputum. Sats increased to 96% —Mary Jones, RN Which type of charting has the nurse used? 1. Narrative 2. Focus 3. SOAP 4. PIE

1

The client asks the nurse whether he should create an advance directive. What information should the nurse share when replying? 1. If he is unable to communicate, his family may make changes to his advance directive. 2. He will not be able to change his advance directive once it is put into writing. 3. An advance directive will ensure he gets as much or as little care as he wishes. 4. He will need to go to a lawyer to have one created.

3

The nurse performs care on an unconscious person at the grocery store. What law protects the nurse in this situation? 1. Medical Treatment and Active Labor Act 2. American Nurses Association Code of Ethics 3. Good Samaritan laws 4. Nurse practice acts

3

Which are common documentation guidelines for nurses? 1. Document ahead when possible. 2. Use block charting. 3. Document after each observation. 4. Never use late entries. 5. Use chronological order. 6. Document throughout the shift.

3,5,6

The nurse, Suzie, has an allergy to latex. Her employer replaced all latex products used on the unit with non-latex substitutions so Suzie will not get sick. What is this an example of? Make the Connection. Drag and drop proper term that is best exemplified by each case scenario. 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Emergency Medical Treatment and Active Labor Act (EMTALA) 3. Patient Self-Determination Act (PSDA) 4. Americans With Disabilities Act (ADA) 5. Good Samaritan Law 6. American Nurses Association Code of Ethics 7. Patient Care Partnership 8. Standard of Practice 9. Nurse Practice Acts 10. Scope of Practice

4

Which regulation requires health-care facilities to provide emergency care to clients who seek health care regardless of ability to pay? 1. Health Insurance Portability and Accountability Act 2. Client Self-Determination Act 3. Durable power of attorney for health care 4. Emergency Medical Treatment and Active Labor Act

4

Protecting Electronic Data - Key actions:

Do not leave the computer unattended after you have logged on Some computer screens are equipped with privacy filters Create a secure password Change your password at regular intervals Do not share your personal user name and password with anyone Do not leave a portable device Never access client health records that you have no professional reason to view Become familiar with your organization's policies

Documentation Do's

Be accurate and nonjudgmental. Adhere to the requirements for reimbursement. Provide details about the client's condition, nursing interventions provided, and client response. Document legibly and as soon as possible. Record significant events or changes in condition. Record any attempts you have made to contact the primary care provider. Chart teaching performed. Chart use of restraints, including reason for use, type of restraints, and frequent checks of the client. Chart any client refusal of treatment or medication. Document any spiritual concerns expressed by the client and your interventions.

Professional Guidelines for Ethical Decision Making

Codes of Ethics for Nurses International Council of Nurses American Nurses Association - Standards of care Patient Care Partnership The Joint Commission

Kardexes

Concise method of organizing and recording data Pertinent information about the client. Quick access. Allergies List of medications including IV fluids

Discharge instructions

Date and time of discharge Who was present, Name and relationship of person(s) accompanying client at discharge Condition of client at discharge Tx to be administered after discharge Signs and symptoms to report Who to contact when reporting a problem Ensure understanding by asking for a return demonstration Time, date and location of follow up appt Detailed instructions Follow-up appointments or referrals given

Computerized Documentation

Developed to manage volume of information Use of computers to store the client's database, new data, create and revise care plans and document client's progress Information easily retrieved Speech-recognition technology Possible to transmit information from one care setting to another

Whistleblowing

Identification of an unethical or illegal situation Can involve one person or an entire organization Reporting such an action to someone in authority Need accurate information May have consequences; THINK before you act American Nurses Association (ANA) working to protect whistleblowers

Health Record System - Problem-Oriented

Organized around client problems Four components: database, problem list, plan of care, and progress notes Promotes greater collaboration

Computer Down Time

Periodic downtimes-scheduled maintenance or network or interface problems Need to know offline and inaccessible Follow organization policies

PIE Documentation

Problem: nausea related to anesthetic. Interventions: pt. given compazine 1 mg iv at 2300. Evaluation: vomited 100 ml clear fluid at 2255. pt. now states no nausea after given Compazine Used only in problem-oriented charting Establishes an ongoing plan of care

How are health records system organized?

Source-Oriented Record System Problem-Oriented Record System

SOAP(IER) Charting

Subjective data: states" I feel sick to my stomach, Help me" Objective data : Vomited 100ml clear, light yellow fluid Assessment: Naused secondary to anesthesia Plan: monitor nausea and give antiemetic as needed - Intervention: administer promethazine 7mg IV at 0830 - Evaluation: states he feels less sick to his stomach - Revision:

Fair access to care and allocation of resources are examples of what type of justice? 1. Distributive 2. Procedural 3. Compensatory 4. General

1

Michelle is in grave condition after an automobile accident. The nurse knows he cannot give a status update to her sister calling from out of state. What is this an example of? Make the Connection. Drag and drop proper term that is best exemplified by each case scenario. 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Emergency Medical Treatment and Active Labor Act (EMTALA) 3. Patient Self-Determination Act (PSDA) 4. Americans With Disabilities Act (ADA) 5. Good Samaritan Law 6. American Nurses Association Code of Ethics 7. Patient Care Partnership 8. Standard of Practice 9. Nurse Practice Acts 10. Scope of Practice

1

There are no legal consequences for nurses who do not follow the ANA Standards of Professional Performance as these are not laws. 1. True 2. False

1

What is an appropriate nursing intervention for moral distress? 1. Self-manage emotions; discuss with mentor if you are having difficulty 2. Decreased anxiety level 3. Assess nature of the action and likelihood of immediate harm 4. Self-determination; to choose and act on that choice

1

What is one major drawback of applying the Golden Rule way of thinking when addressing a client's wishes? 1. It is presumptuous in that nursing actions may not really be what the client wants. 2. It removes all grounds for client autonomy. 3. It removes the family from decision making. 4. It blurs the role of nurse, advocate, and ethical decision making.

1

The nurse is documenting in a health record at the client's bedside. The client says, "It seems like nurses spend most of the day documenting. What a waste of time!" Which statements would provide a correct response? Select all that apply. 1. "Written documentation is important in communicating pertinent data to the healthcare team." 2. "Written documentation is to serve as a record of accountability for accreditation." 3. "The written documentation can serve as a legal record for the healthcare provider." 4. "Written documentation serves as a record of accountability for quality assurance and improvement." 5. "Written documentation proves I did what the doctor ordered and gave good, quality care."

1,2,3,4

The nurse is reviewing documentation forms in the facility where she was recently hired. What are some commonly used forms? Select all that apply. 1. Checklists 2. Medication administration records 3. Intake and output records 4. Care plans 5. Kardex

1,2,3,4,5

What are some advantages of electronic records? 1. More secure 2. Neater and easier to read 3. Can transfer information to multiple departments 4. Can be used by several people at once 5. Less repetition 6. More accurate 7. Less "down time" 8. Saves time for nurses

1,2,3,4,5,6,8

Which are common forms of oral communication? 1. Transfer report 2. SBAR 3. Bedside report 4. Face-to-face report 5. Kardex 6. Verbal orders 7. Handoff report 8. Telephone orders

1,2,3,4,6,7,8

An informatics nurse is training a group of students on the advantages of using an EHR. What could be some supporting reasons? Select all that apply. 1. Can be used by several team members simultaneously 2. Less repetition of data 3. More accurate reporting 4. Less "down time" 5. Faster

1,2,3,5

The nurse understands that the electronic health record (EHR) has which advantages over paper charting? Select all that apply. 1. Facilitates evidence-based nursing practice 2. Promotes efficient use of the nurse's documentation time 3. Reduces the opportunity for interdisciplinary collaboration 4. Ensures improved client safety and outcomes 5. Less cost intensive and easier to maintain

1,2,4

Which are forms of electronic communication? Select all that apply. 1. Email 2. Telephone 3. Text message 4. Telehealth 5. Interoffice memo

1,3,4

What are some common charting formats? 1. Problem—Intervention—Evaluation 2. Summarize, Organize, Assessment, Plan, Implement, Evaluate 3. Narrative 4. SOAPIE 5. Exception 6. Medication Administration Record 7. Emergency 8. Focus Charting®

1,3,4,5,8

Which questions are examples of bioethics considerations? Select all that apply. 1. Should a client be allowed to die? 2. Should a nurse practice outside of scope? 3. Should a nurse question an order? 4. Should a nurse sign with "RN" behind her name? 5. Should a client be told about a medical error?

1,3,5

Which statements about documentation are correct? Select all that apply. 1. The chart is a legal document and is admissible in court. 2. Items required in the nurse's documentation are mandated by government agencies. 3. Each healthcare agency follows one charting format. 4. Standardized nursing language provides a clear picture of client outcomes. 5. A problem list is a list of potential treatment complications.

1,4

According to the Health Information Portability and Accountability Act Privacy Rule, protected health information can only be shared for which purposes? Select all that apply. 1. Treatment 2. To ensure everyone on a nursing unit is aware of the client 3. Reassurance to family 4. Payment 5. Operations 6. Understanding past treatments

1,4,5

The nurse is explaining the Health Insurance Portability and Accountability Act to a group of new employees. What should the nurse include when explaining its purpose? Select all that apply. 1. Protects health insurance benefits 2. Provides transferability of insurance to others 3. Protects family members 4. Protects those with preexisting conditions 5. Provides personal health information privacy

1,4,5

Which are commonly used documentation forms? 1. Flow sheets and graphic records 2. Family relationship form 3. Hand-off report 4. Admission data forms 5. Student tracking form 6. History and physical 7. Discharge summary 8. Occurrence report

1,4,6,7,8

The newly graduated nurse is supervising licensed practical nurses and certified nursing assistants. It is important to understand the role of each person. What is this an example of? Make the Connection. Drag and drop proper term that is best exemplified by each case scenario. 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Emergency Medical Treatment and Active Labor Act (EMTALA) 3. Patient Self-Determination Act (PSDA) 4. Americans With Disabilities Act (ADA) 5. Good Samaritan Law 6. American Nurses Association Code of Ethics 7. Patient Care Partnership 8. Standard of Practice 9. Nurse Practice Acts 10. Scope of Practice

10

Jason just vomited blood but is hesitant to go to the emergency department because he does not have insurance. He tells this to the admitting nurse, who assures him he won't be turned away from medical care. What is this an example of? Make the Connection. Drag and drop proper term that is best exemplified by each case scenario. 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Emergency Medical Treatment and Active Labor Act (EMTALA) 3. Patient Self-Determination Act (PSDA) 4. Americans With Disabilities Act (ADA) 5. Good Samaritan Law 6. American Nurses Association Code of Ethics 7. Patient Care Partnership 8. Standard of Practice 9. Nurse Practice Acts 10. Scope of Practice

2

Trina, an RN on the nursing unit, states to the student nurse, "I see you are working with Beth today. Make sure you watch your patient carefully because I think Beth is one of our worst nurses." The student knows that this statement could be considered 1. Libel 2. Slander 3. Fraud 4. Invasion of privacy

2

Upon initial assessment of an older adult, the nurse discovers bruises and scratches on the client's arms, legs, and trunk in various stages of healing. The supervisor is notified that physical abuse is suspected. With which of the following is the nurse in compliance? 1. Good Samaritan laws 2. Mandatory reporting laws 3. Nurse practice act 4. Patient Self-Determination Act 5. Nursing Standards of Practice

2

Which abbreviations are on The Joint Commission's "do not use" list? 1. oz for ounce 2. U or u 3. IU 4. MS for magnesium sulfate 5. Q.D. for daily 6. Q.O.D. 7. Lack of leading zero (.X mg) 8. q for every

2,3,4,5,6,7

Which guidelines are established for nursing practice? Select all that apply. 1. Manual of Labor 2. Standards of Practice 3. Patient Care Partnership 4. Scope of Responsibility 5. Nurse practice acts

2,3,5

A 15-year-old male comes to the clinic seeking treatment for "a problem." The nursing history reveals the client may have a sexually transmitted infection (STI). Which is the most appropriate initial response by the nurse? 1. "I will need a list of all the people with whom you have had relations." 2. "Have you told your parents about this situation?" 3. "Let's discuss how you feel about this situation." 4. "You will need to practice safe sex. Let's discuss how to use condoms."

3

A client is asking about developing a living will. What act protects this right? 1. Americans With Disabilities Act 2. Emergency Medical Treatment and Active Labor Act 3. Patient Self-Determination Act 4. Health Insurance Portability and Accountability Act

3

A pregnant 16-year-old girl is admitted to the emergency department in active labor. Her mother says she has no money or insurance. What should the nurse do next? 1. Arrange for an ambulance to transport her to the nearest public hospital. 2. Explain to the girl and her mother that the hospital only accepts patients who can pay the hospital bill. 3. Examine her to determine whether her condition is stable or whether she requires immediate medical attention. 4. Inform her mother that she will need to transport her daughter to the nearest public hospital. 5. Encourage the mother to find alternative sources of payment.

3

How can nurses use computers to ensure they are following best practices? 1. Join a chat room with other nurses. 2. Ask a question on social media. 3. Perform a literature search. 4. 3Type a keyword into a browser.

3

Josephine wants to make her own decisions about her end-of-life care. She talks to her significant other about creating a living will and durable power of attorney. What is this an example of? Make the Connection. Drag and drop proper term that is best exemplified by each case scenario. 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Emergency Medical Treatment and Active Labor Act (EMTALA) 3. Patient Self-Determination Act (PSDA) 4. Americans With Disabilities Act (ADA) 5. Good Samaritan Law 6. American Nurses Association Code of Ethics 7. Patient Care Partnership 8. Standard of Practice 9. Nurse Practice Acts 10. Scope of Practice

3

The nurse documents: D: The client is wheezing and experiencing some shortness of breath with exertion A: Delivered 2 puffs of inhaler. R: Wheezing lessened after 5 minutes. Which type of documentation is this an example of? 1. PIE 2. Charting by exception 3. Focus Charting® 4. Narrative

3

On admission to Hospital A, the patient indicates that he would like information about making a living will. The nurse informs the patient that the hospital does not have a process in place to facilitate this. Hospital A is not in compliance with the 1. Health Insurance Portability and Accountability Act 2. Emergency Medical Treatment and Active Labor Act 3. Americans with Disabilities Act 4.Patient Self-Determination Act

4

An older adult has a terminal cancer and has been in the hospital for 4 days. Her daughter visits and says to the nurse, "My mother claims she has an infection, but I know she is not telling me the truth." The daughter asks the nurse to tell her what is really happening. How should the nurse respond? 1. "Your mother has an inoperable brain tumor, but does not want anyone to know." 2. "You need to speak to the primary healthcare provider in charge of your mother's care." 3. "Your mother has requested that her case not be discussed with anyone, not even family." 4. "Your mother is very sick with a serious case of pneumonia that could lead to death." 5. "You need to speak to your mother about this; I'm not able to give information."

5

Henry, a nurse, is driving home from work when there is a major motor vehicle accident in front of him. He runs to the side of the driver, finding him bleeding from the nose and mouth. Henry calls 911 and begins treating the driver after receiving consent. What is this an example of? Make the Connection. Drag and drop proper term that is best exemplified by each case scenario. 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Emergency Medical Treatment and Active Labor Act (EMTALA) 3. Patient Self-Determination Act (PSDA) 4. Americans With Disabilities Act (ADA) 5. Good Samaritan Law 6. American Nurses Association Code of Ethics 7. Patient Care Partnership 8. Standard of Practice 9. Nurse Practice Acts 10. Scope of Practice

5

Harriet accepted money from a client as a "thank you" gift. Her employer found out and fired her. What is this an example of? Make the Connection. Drag and drop proper term that is best exemplified by each case scenario. 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Emergency Medical Treatment and Active Labor Act (EMTALA) 3. Patient Self-Determination Act (PSDA) 4. Americans With Disabilities Act (ADA) 5. Good Samaritan Law 6. American Nurses Association Code of Ethics 7. Patient Care Partnership 8. Standard of Practice 9. Nurse Practice Acts 10. Scope of Practice

6

Johnston would like to better understand his hospital bill. He calls the hospital and the billing department suggests he meet with a representative and have it explained. What is this an example of? Make the Connection. Drag and drop proper term that is best exemplified by each case scenario. 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Emergency Medical Treatment and Active Labor Act (EMTALA) 3. Patient Self-Determination Act (PSDA) 4. Americans With Disabilities Act (ADA) 5. Good Samaritan Law 6. American Nurses Association Code of Ethics 7. Patient Care Partnership 8. Standard of Practice 9. Nurse Practice Acts 10. Scope of Practice

7

Legal and Ethical: Standards for Documentation *Client's record is a legal document* *May be used to provide evidence in court*

Date and time Timing Legibility Permanence Accepted terminology Correct spelling Signature Accuracy Sequence Appropriateness Completeness Conciseness Legal prudence

Ethical Decision Making

Recognize an Ethical Issue -> Get the Facts -> Evaluate Alternative Actions -> Make a Decision and Test on It -> Act and Reflect on Outcome

EHR -- Important Data Entry Facts

Before opening charting forms- - Ensure patient's name, ID, MRN EHR- review partially completed documentation before signing it. EHR-saved document is not seen by others until it is signed If you make an error*, it can be corrected: the entry can never be completed deleted. But only the corrected info will be visible to anyone viewing the chart

Federal Laws Guiding Nursing Practice

Bill of Rights Health Insurance Portability and Accountability Act (HIPAA) Emergency Medical Treatment and Active Labor Act Health Information Technology for Economic and Clinical Health (HITECH) Patient Self-Determination Act (PSDA) Americans with Disabilities Act (ADA)

Narrative Charting

Can use with source- or problem-oriented system "Story" of care in chronological format Tracks the client's changing status Can be lengthy and disorganized

Processes for Ethical Practice

Clarify your values. Identify moral dilemmas. Use a decision-making model. - M O R A L Look for a compromise. Participate on an ethics committee. Improve your ethical decision making.

Ethical Problems for Nurses: Sources

Consumer awareness: Informed consent Technological advances: We CAN, but should we? Multicultural population: Differing ethics Cost containment: Unequal access Nature of the work Nature of the profession

Documentation Don'ts

Don't chart a symptom, such as "c/o pain," without also charting what you did about it. Don't alter a patient's record- -this is a criminal offense. Don't use shorthand or abbreviations that aren't widely accepted. Don't write imprecise descriptions, such as "bed soaked" or "a large amount." Don't give excuses, such as "Medication not given because not available." Don't chart what someone else said, heard, felt, or smelled unless the information is critical. In that case, use quotations and attribute the remarks appropriately. Don't chart care ahead of time--something may happen and you may be unable to actually give the care you've charted. Charting care that you haven't done is considered fraud

Common Malpractice Claims

Failure to assess and diagnose Failure to plan Failure to implement a plan of care Failure to evaluate

Nurses as Ethical Agents

Know the difference between right and wrong. Understand abstract ethical principles. Apply ethical principles in decision making. Weigh alternatives; plan to achieve goals. Decide and choose freely. Act according to choice. Consider value neutrality.

Standards of Practice

Standard of care - What a reasonable and prudent nurse would do in the same or a similar scenario Derived from - Nurse practice acts (NPAs) - Professional organizations - The Joint Commission

Guidelines for Documentation

When to document: After care or assessment Beginning of shift Chronologically, to communicate changing status *Never chart ahead* Avoid "block" charting: e.g., from 1300 to 1500 Late entries, paper: need to clearly designate that this is a late entry: "date, time", "late entry", details, then sign. Late entries, EHR: change the current date and time to the data/time that your care was actually done.

Ethical Principles: Beneficence

duty to do or promote good

Perception of nurses

the most trusted profession and voted the most ethical and honest profession in for 14 of the past 15 years.

Liability

the person is financially or legally responsible for something

Ethical Principles: Nonmaleficence

to do no harm and to prevent harm