Legal Terminology
The patient agrees to the procedure
Consent
What you are requesting
Recommendation
How long this will take
Time
What the patient says it is
Subjective
Negligence
In charge of financial decisions
Power of Attorney
Relevant medical history
Back ground
Who you are and who the patient is
acknowledge
When nurses should document
Contemporaneously
Taking reasonable steps to ensure safety
Duty of care
Enduring guardianship
Who and where you are
Introduction
Why and how you will do the task
Explanation
Factual documentation ie Bp or RR
Objective
Protected by employer whist working within scope of practice
Vicarious Liability
Civil law that provides remedies for harm caused by harmful conduct
Tort Law
What is happening
Situation
what you do prior to entering a room, after touching equipment and patient space and on leaving the room
Hand Hygiene
What colour ink we should write with
Open conversation post an incident
Open disclosure
Civil Law
Objective information
Assessment
How long the procedure will take
Duration
What all medical terminology should be ... Drs are the worst
Legible
Moral principals that guide a nurses conduct
Ethics