exam 3: chapter 20 (documentation), chapter 21 (informatics), chapter 7 (legal implications)

Question 1

__ (statutory/administrative) law is enacted by a legislative body. nursing practice acts are this law

Answer 1

statutory

Question 2

__ (statutory/administrative) law is empowered by executive officers. the rules and regulations under the board of registration in nursing is this law.

Answer 2

administrative

Question 3

the professional standards of nursing is __

Answer 3

ana standards of nursing practice

Question 4

__ (credentialing/licensure/certification) is how professional competence maintained and ensured

Answer 4

credentialing

Question 5

__ (licensure/accreditation/certification) is the process by which educational program is evaluated to meet standards

Answer 5

accreditation

Question 6

__ (licensure/accreditation/credentialing) meets minimal requirements and grants license to practice nursing

Question 7

__ (certification/accreditation/licensure) is specialty knowledge proficiency granted by non-governing body

Answer 7

certification

Question 8

the __ is the most important law affecting your nursing practice

Answer 8

state nurse practice act

Question 9

true or false. each state has nurse practice acts.

Answer 9

true

Question 10

true or false. the nurse practice acts do NOT protect the public.

Answer 10

false. the nurse practice act protect the public.

Question 11

__ broadly defines the scope of nursing practice, is studied carefully before applying for licensure, is the who, what, when, where, and why of nursing practice, are needed to be practiced, and can result in disciplinary action from the board of registration in nursing

Answer 11

the nurse practice acts

Question 12

__ (the nurse practice acts/statutory law/reasons for suspending or revoking a license) include:
drug or alcohol abuse (most frequent reason)
fraud
deceptive practice
criminal acts
precious disciplinary actions
gross or ordinary negligence
physical or mental impairments

Answer 12

reasons for suspending or revoking a license

Question 13

misdemeanor and felony is considered a __ (crime/tort)

Answer 13

crime

Question 14

__ (a crime/a tort) can be intentional and unintentional

Answer 14

a tort

Question 15

assault (threat to make bodily contact), battery (actual contact), defamation of character, invasion of privacy, false imprisonment, and fraud are considered __ (intentional/unintentional) tort

Answer 15

intentional

Question 16

negligence (below the standard of care, “reasonably prudent person”) and malpractice (negligence of a professional person) are part of __ (intentional/unintentional) torts

Answer 16

unintentional

Question 17

__ (standards of practice/credentialing/malpractice claims) include the failure to:
- follow standards of care
- use equipment in responsible manner
- assess and monitor
- communicate
- document
- act as a pt advocate

Answer 17

malpractice claims

Question 18

the four elements of liability of malpractice elements are: __, __, __, and __

Answer 18

breach of duty
causation
duty
damages

(bcdd)

Question 19

__ (duty/causation/damages/breach of duty) is the obligation to use due care. this is what a reasonable and prudent nurse would have done in the same circumstances. defined by standard of care.

Answer 19

duty

Question 20

__ (duty/causation/breach of duty/damages) is the failure to meet the standard of care

Answer 20

breach of duty

Question 21

__ (duty/breach of duty/causation/damages) is the actual harm or injury that occurred to the pt

Answer 21

damages

Question 22

__ (duty/damages/breach of duty/causation) is the need to prove that failure to meet the standard of care (breach of duty) caused harm or the injury

Answer 22

causation

Question 23

good __ usually makes proof impossible

Answer 23

documentation

Question 24

the most popular minimizing chance of liability is __ (maintain clinical competence/ practice within legal boundaries of practice/refusing to accept responsibilities for which you are unprepared)

Answer 24

refusing to accept responsibilities for which you are unprepared

Question 25

all of the following are examples of __ (minimizing chance of liability/confidentiality/standard of practice) - practice w/in LEGAL boundaries of practice - promptly and accurately document all assessments and care - perform procedures correctly and appropriately - administer the 6 rights - following institutional procedures and policies - delegate appropriately - protect clients from injury - report all incidents - always check any order that is questioned - know own strengths and weaknesses - maintain clinical competence - refusing to accept responsibilities for which you are unprepared

Answer 25

minimizing chance of liability

Question 26

are these safeguards (legal) for nurses? true or false. - competent practice - informed consent or refusal - contracts - collective bargaining - pt education - executing physician orders - delegating nursing care - documentation - appropriate use of social media - adequate staffing (aacccddei)

Answer 26

true

Question 27

what are other legal safeguards for nurses?

Answer 27

- good samaritan laws - incident, variance, occurence reports - just culture - pt's rights - professional liability insurance - risk management programs - sentinel events and never events - student liability - whistle-blowing (gijpprssw)

Question 28

true or false. all info abt pts 1) written on paper, 2) spoken aloud , and 3) saved on computer are confidential

Answer 28

true

Question 29

1) info abt past health conditions 2) name, address, phone, fax, ssn 3) reason the person is sick 4) treatments pt receives are examples of __

Answer 29

confidential

Question 30

is discussing info in public areas an invasion of privacy?

Answer 30

yes

Question 31

interacting with the pt's family in ways not authorized by the pt is not an invasion of privacy. true or false.

Answer 31

false. it is.

Question 32

using tape recorders, dictating machines, computers w/o taking precautions to ensure the pts confidentiality are invasions of privacy. true or false.

Answer 32

true

Question 33

improperly accessing info is an invasion of privacy. true or false.

Answer 33

true

Question 34

preparing school assignments abt pts w/o concealing their identity is not an invasion of privacy. true or false.

Answer 34

false. it is.

Question 35

social networks are not an invasion of privacy. true or false.

Answer 35

false. it is.

Question 36

__ (invasion of privacy/ensured pt rights/standards of practice) are to: - see and copy their health record - update their health record - request correction of any mistakes - get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations - request a restriction on certain uses or disclosures - choose how to receive health info

Answer 36

ensured pt rights

Question 37

the elements of informed consent include: (ccdv)

Answer 37

competence, comprehension, disclosure, voluntaries

Question 38

communication diagnostic and therapeutic orders care planning quality process and performance improvement research; decision analysis are examples of __ (causes/purposes/reasons) of pt records

Answer 38

purposes

Question 39

education credentialing, regulation, legislation reimbursement legal and historical documentation are also examples of __ of pt records

Answer 39

purposes

Question 40

components of a medical record include (accdifppm):

Answer 40

acuity record care plan critical collaborative pathways discharge and transfer summary initial nursing assessment flow sheets and graphic records pt care summary progress notes med record

Question 41

electronic medical records are a __ and __ database

Answer 41

uniform; standardized

Question 42

you should never give your personal password to anyone. true or false.

Answer 42

true

Question 43

don't leave computer open and unattended. true or false.

Answer 43

true

Question 44

someone can chart under your name. true or false.

Answer 44

false. no one should chart under your name