Terms
Any demand for payment from an entity or individual, including a UCLA employee, which is disputed in whole or in part.
What is claim?
Nursing Clinical Note or SOFI?
FACTS about a negative situation can be documented in the Legal Medical Record.
What is nursing clinical note?
Informed Consent is a ________; NOT completing a form.
What is process?
Name (2) reasons why a nurse would alert risk management.
Surgery & Invasive Procedures: Iatrogenic complications, Air Embolism, Burns, Retained Foreign Objects, Instrument Fragment, Needle(s), Guide Wire Drains, Sponge(s) , Pt. Injury from a device
Never Events: Wrong site, procedure or patient, Infant abduction, Missing pt, Suicide, Physical Assault on staff or patient
Maternal Complications: Death, Eclampsia, Hysterectomy, Postpartum Hemorrhage, Symptomatic uterine rupture, Sterilization w/o consent.
Infant Complications: Apgar <3, Brachial Plexus Palsy, Cord pH <7.0, Fractured skull, Meconium aspiration, Air Embolism (amniotic fluid)
A nurse can become a _________ _________ ________ or GCN. This credentialing is by GNCC and the RN needs to meet certain requirements.
What is Genetics Clinical Nurse?
An adverse event or complication resulting in an unanticipated outcome, including death, brain damage, permanent paralysis, sensory deficits, partial or complete loss of hearing or sight, birth injury or disability, or other catastrophic damage or permanent disability; an incident that has produced an actual, potential or perceived injury or potential claim.
What is liability?
Nursing Clinical Note or SOFI?
Provide specific details that should not go into the EMR. What actually occurred, what happened, how did it happen, recommendations for improvement.
What is SOFI?
Durable Power of Attorney Health Care – Spouse, children
Conservatorship, Court Orders, Third Party.
These are all examples of __________ decision makers. Must show proof (legal documentation) before or at the time of signing consent.
What is surrogate?
It is vital to control loss. One way is through effective communication. The nurse must perform a _______ _____ anytime an invasive procedure is performed.
What is time out?
The process of helping people understand and adapt to the medical, psychological, and familial implications of hereditary disease.
What is genetic counseling?
•It can reduce the risk of claims and medical litigation if the record is complete and accurate.
• Demonstrates to patient and family that the appropriate interventions were carried out timely.
• Assists the Expert Witness when testifying
• Assists with Regulatory Compliance (The Joint Commission (TJC) and CDPH.
• It helps answer questions the family have about the adverse / medication or fall events.
What is documentation?
Nursing Clinical Note or SOFI?
Document interventions, outcome of a situation and any leadership interventions with family or patient.
What is nursing clinical note?
There are some patients who REFUSE to receive information about their surgery, procedure or anesthesia and that is acceptable. However, consequences of the decision maker’s refusal Must be explained and clearly documented by the _________ in Care Connect.
Who is physician?
Regarding equipment malfunction: Whether or Not there was harm to the patient, we are required to make a report to the _______. Make sure you inform risk management and sequester equipment /supplies involved.
Who is FDA?
Name at least one person who would seek genetic counseling.
Who is......
Pregnant women (couples)
Individuals with family history of disease
Family with children/adults with developmental delay/mental retardation
Family with children/adults with birth defects
Individuals with unexplained medical issues
“A negative or unexpected result stemming from a diagnostic test, medical judgment or treatment, surgical intervention, or from the failure to perform a test, treatment or intervention. It is not necessarily the result of medical error or professional negligence”.
What is unanticipated event?
Proper nursing documentation includes:
Do a thorough assessment: Document Objective and Subjective
Make sure you refrain from your own theories about what is going on. Don’t speculate. Stick with the _________.
What is facts?
True or False: All attempts were made to contact next of kin. But this patient does not have any family. The patient needs surgery. Therefore, TWO physicians must consent for the procedure to take place.
What is false?
There is no such thing as two (2) physician consent. It is a myth. The MD must document in the progress note.
An __________ should be done within hours post event and no longer than 24 hours. Respond in a timely fashion – Delays can look like a cover up.
What is apology.
How does a person get genetic testing? Clinical genetic tests are ordered by an MD. Generally involves a blood test, with specific collection and shipping requirements. Ideally, the person is referred to a ___________ __________and meets with a geneticist or genetic counselor to discuss genetic testing
What is genetics clinic?
A _______ of _______ note documents discussions and decisions about future medical treatments including conversations to enhance prognostic awareness, discussions leading to or failing to yield a completed advance directive, patient preferences concerning future health states and treatments, conversations leading to a POLST, and nuanced discussions about future care goals or health states.
What is Goals of Care?
Proper nursing documentation includes:
Describe your interventions and the patient’s response: Include essential ___________ with other clinicians, especially the doctor. Include with whom you consulted, what you told them and what their responses were. Include any diagnostic tests arising from your assessment.
Evaluate your actions: Evaluate and list the effectiveness of your ___________ by describing the patient's response.
What is conversations and interventions?
Treatment of a _________ _____________ may be provided without consent where the provider reasonably believes that a medical procedure should be undertaken immediately and there is insufficient time to obtain consent.
What is medical emergency?
Following the event, its vital to _________ information the patient/family. The goal is to dispel anger, confusion and distrust.
What is disclose?
The process of detecting chromosomal abnormalities.
What is karotyping.