Legal Eagles
Did you write it down?
Communication Breakdown
Is it therapeutic?
Dealer's Choice
(potpourri)
100

These prescribe proper behavior in society; they sanction appropriate behavior and prohibit unacceptable behavior. 

What are laws

100

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. 

100

Your patient has a pill due at 1:15 p.m. How is this documented using military time? 

What is 1315? 


100

Seeking to understand the patient's message by asking for more information or elaboration on a point. 

What is clarifying?

100

This is the very best way to avoid a lawsuit. 

What is to provide compassionate, competent nursing care

200

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. 

200
From the mnemonic D.A.R.E., nurses know that the letters stand for:
D- Data
A- ___________
R- Response & evaluation
E- Education & patient teaching.

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. 

200

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. 

200

The medical record: is this considered a primary or secondary source of data?

What is a secondary source?

200

Pain- a subjective or objective finding?

What is subjective?

300

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. 

300

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? 

300

Using the mnemonic ISBAR, nurses know that the S stands for ________. 

What is situation

I- identification

S- situation

B- background

A- assessment

R- recommendation

300

Restatement of the patient's message in the nurse's own words.

What is paraphrasing?

300

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. 

400

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?

400

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

400

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?

400

Questions that do not require a specific "yes" or "no", and give the patient the opportunity to elaborate.

What are open-ended questions?

400

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?

500

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?

500

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. 

500

When patients are unable to send the desired verbal message, it is this type of aphasia.

What is expressive aphasia?

500

List four non-verbal therapeutic techniques. 

1. Active listening

2. Maintaining Silence

3. Touch

4. Conveying Acceptance

5. Minimal Encouragement

500

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.