Legal aspects of Nursing
Documentation
History of Nursing
100

The absence of due care or The failure to act in a manner demonstrating the care and knowledge any prudent individual would use.  

What is Negligence

100

Method of communicating among health care workers and a part of documentation of communication that has occurred among health care staff.  

What is ISBAR (identification, situation, background, assessment and recommendation) 

100

*Known as “Lady with the Lamp”

* Credited as the first nursing theorist

*Helped to shift the views of nursing education

Who is Florence Nightingale

200

A written document that directs treatment in accordance with a patient's wishes in the event of a terminal illness or conditions.

What is a living will.

200

Developed to meet the nursing care needs of a patient; which outlines the proposed nursing care based on the assessment and the identified patient problems to provide continuity of care. 

What is the Nursing care plan

200

*Founded by Lillian Kuster in 1949

* Membership limited to LPN/LVN's

What is the National Federation of Licensed Practical

Nurses (NFLPN)

300

Person designates an agent, surrogate, or proxy to make health care decisions on the person's behalf based on the patient's wishes.

What is a durable power of attorney.

300

Form used to document any event not consistent with the routine operation of a health care unit or the routine care of a patient. 

What is an incident report. (Does not go in patient's medical record)

300

*Established the Department of Practical

Nursing Programs in 1961.

*Developed an accreditation service for these

programs, which today is called the Council of

Practical Nursing Programs.


Who is the National League for Nursing (NLN).

400

Signed and witnessed documents that provide specific instructions for health care if a person is unable to make decisions personally at the time they are needed. 

What are Advance directives. 

400

Provides important information that pertains to the patient's continued health care after when patient leaves the hospital. (Starts on admission and should involve patient and family)

What is Discharge planning/summary. 

400

Organized the American Society of Superintendents of Training schools of Nursing in 1893. 

Who is Isabel Hampton Robb and Lavinia Dock. 

500

Ethical principle to do no harm and act in the patient's best interest; an ethical and legal duty to do nothing that has a harmful effect on the patient. 

What is Nonmaleficence

500

May lead to nursing malpractice, not charting the correct time events occurred or that an event occurred at all; failing to record orders, charting nursing care in advance and charting incorrect data. 

What is inappropriate documentation. 

500

Pioneer crusader for elevation of standards of care for the mentally ill. Superintendent of Female nurses of the Union Army. 

Who is Dorothea Dix