Legal Eagles
These prescribe proper behavior in society; they sanction appropriate behavior and prohibit unacceptable behavior.
What are laws?
The patient complains of nausea. This is _____________ data.
What is subjective?
Subjective data or complaints can only be communicated by the patient because it is something the patient feels or states.
Your patient has a pill due at 1:15 p.m. How is this documented using military time?
What is 1315?
Seeking to understand the patient's message by asking for more information or elaboration on a point.
What is clarifying?
This is the very best way to avoid a lawsuit.
What is to provide compassionate, competent nursing care?
A malicious or untrue writing about another person that is brought to the attention of others.
What is libel?
Slander is malicious or untrue spoken words brought to the attention of others.
What is action? The mnemonic D.A.R.E. is used for focus charting. Action is a combination of planning and the implementation of nursing interventions.
Who owns the original health care record or chart?
The original health care record/ chart is the property of the institution or the health care provider.
The medical record: is this considered a primary or secondary source of data?
What is a secondary source?
Pain- a subjective or objective finding?
What is subjective?
The ethical principle in nursing meaning to do no harm.
What is nonmaleficence?
Nurses must act in the patient's best interest and have an ethical and legal duty to do nothing that has a harmful effect on the patient.
The occurrence of an accident or unexpected event should be documented as a(n) __________ report. Though employees regard these as punitive, they truly are not and are generated to improve system processes or policies.
What is an incident or variance report?
Using the mnemonic ISBAR, nurses know that the S stands for ________.
What is situation?
I- identification
S- situation
B- background
A- assessment
R- recommendation
Restatement of the patient's message in the nurse's own words.
What is paraphrasing?
Malpractice refers to professional negligence. There are four key elements required to prove malpractice, and each must be present to establish liability. Those elements are: duty, breach of duty, harm, and _________.
What is proximate cause?
There was a duty to act; the nurse violated that duty (breach) resulting in harm; and that breach was the proximate cause of the harm.
As an exception to the right of privacy, nurses are considered _________ reporters, especially in cases of suspected child or vulnerable adult abuse.
What is a mandated reporter?
To alleviate the time-consuming, defensive, detailed narrative method of charting, this type of charting rose to popularity. Though all care must be charted, with this type of charting, nurses can utilized more detailed flowsheets to enhance the focus on existing concerns.
What is charting by exception?
Trying to impose the nurse's own attitude, values, beliefs, and moral standards on a patient regarding what is wrong or right is this type of communication blocking response.
What is approval or disapproval?
Questions that do not require a specific "yes" or "no", and give the patient the opportunity to elaborate.
What are open-ended questions?
Stereotyped or superficial comments (like, "You can't win 'em all.") that do not focus on what the patient is feeling or trying to say represent this type of communication blocker.
What are automatic responses?
An example: An adult alert patient has refused an IM injection, but the nurse gives it when the patient is asleep. This nurse could be charged with ________.
The unlawful touching of another person without informed consent.
What is battery?
If you did not chart it, __________________.
YOU DID NOT DO IT!
That's the ultimate rule of documentation- if you didn't chart it, you didn't do it.
When patients are unable to send the desired verbal message, it is this type of aphasia.
What is expressive aphasia?
List four non-verbal therapeutic techniques.
1. Active listening
2. Maintaining Silence
3. Touch
4. Conveying Acceptance
5. Minimal Encouragement
What are the four things that are needed to prove malpractice?
1. Duty to act
2. Breach of duty
3. Harm occurred
4. Harm occurred from the proximate cause of the breach.