CHARTING
finish the phrase " If you didn't document it,
It didn't happen!
Nurse fails to provide standard care and safe care to a patient and puts client at risk for harm
When a patient leaves the healthcare facility before the course of treatment is completed against the wishes of the provider is called
Leaving Against Medical Advice
What is an advanced directive?
A legal document outlining a person's medical treatment preferences whenever they are unable to make decisions, so health professionals treat and family honor the patient autonomy
Which law protects providers of emergency care in good faith from liability for unintentional harm to encourage laypersons and off-duty clinicians to provide assistance in emergency situations without fear of civil liability?
Good Samaritan Law
A documentation of when an unusual event or a change in the patient's condition occurs. Is what type of charting?
Charting by exception
Name a guideline for restraint use
1. restrained must be ordered by physician
2. informed consent must be obtained
3.must document ongoing assessment
4. must monitor patient
5. regulations regarding how to use restrained must be strictly followed
A patient who leaves a hospital having received only some of the care recommended without completing it is called
Leaving without treatment
What is the name of the document that is intended for the seriously ill and includes specific medical orders such as CPR, ventilation, and artificial nutrition?
POLST
Give an example of hospital liability
Corporate negligence
Hospital acquired infections
Emergency room errors
Inadequate staffing
Hospital negligence
Employee negligence
What does each letter in SOAP charting stand for?
S-Subjective
O-Objective
A-Assessment
P-Plan
What is the definition of a tort?
Wrongful act that causes harm to another person
What is the definition of a sentinel event?
A serious unexpected adverse event in healthcare that results in death permanent harm or severe temporary harm to a patient
What is a practice in some areas that allows patients who are terminally ill to request medications to end their lives?
Medical Aid in Dying
What is a practice in some areas that allows patients who are terminally ill to request medications to end their lives?
Medical Aid in Dying
Name 2 advantages of narrative charting
Provide more information regarding patients overall health status
More detailed
Gives other health care providers a “full picture” of the patient
Includes all essential information
More efficient care
Who oversees the practices of nursing in each state?
State Boards
What should you NOT do when completing an incident report?
Do not use assumptions
Example: “The patient slipped in the bathroom.”
Do not document it in the patient’s health record
Do not use medical abbreviations
What is one of the key ethical and legal principles in health practice that ensures that the patients can understand their treatment options?
Informed consent
Legal responsibility of providers for their actions during the care of a patient is known as?
Personal Liability
What does DAR in focus charting stand for?
D-Data
A-Action
R-Response
What should you DO when completing an incident report?
complete an incident report ASAP after the occurrence of the incidence
write only OBJECTIVE facts
Example: “Patient found on the floor in the bathroom.”
Detailed description of what occurred
Direct quotes from witnesses
Any interventions done to the patient who was affected due to the incident
Give 2 examples of what the Patient Bill of Right entails
High quality hospital care
Clean and safe environment
Involvement in care
Protection of privacy
What is futility of care?
Medical treatments unlikely to benefit the patient, mostly in the end stage of life.