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

1
Q

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

A

statutory

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2
Q

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

A

administrative

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3
Q

the professional standards of nursing is __

A

ana standards of nursing practice

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4
Q

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

A

credentialing

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5
Q

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

A

accreditation

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6
Q

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

A
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7
Q

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

A

certification

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8
Q

the __ is the most important law affecting your nursing practice

A

state nurse practice act

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9
Q

true or false. each state has nurse practice acts.

A

true

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10
Q

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

A

false. the nurse practice act protect the public.

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11
Q

__ 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

A

the nurse practice acts

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12
Q

__ (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

A

reasons for suspending or revoking a license

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13
Q

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

A

crime

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14
Q

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

A

a tort

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15
Q

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

A

intentional

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16
Q

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

A

unintentional

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17
Q

__ (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

A

malpractice claims

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18
Q

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

A

breach of duty
causation
duty
damages

(bcdd)

19
Q

__ (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.

A

duty

20
Q

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

A

breach of duty

21
Q

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

A

damages

22
Q

__ (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

A

causation

23
Q

good __ usually makes proof impossible

A

documentation

24
Q

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)

A

refusing to accept responsibilities for which you are unprepared

25
Q

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

A

minimizing chance of liability

26
Q

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)

A

true

27
Q

what are other legal safeguards for nurses?

A
  • 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)
28
Q

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

A

true

29
Q

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 __

A

confidential

30
Q

is discussing info in public areas an invasion of privacy?

A

yes

31
Q

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

A

false. it is.

32
Q

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

A

true

33
Q

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

A

true

34
Q

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

A

false. it is.

35
Q

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

A

false. it is.

36
Q

__ (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

A

ensured pt rights

37
Q

the elements of informed consent include: (ccdv)

A

competence, comprehension, disclosure, voluntaries

38
Q

communication
diagnostic and therapeutic orders
care planning
quality process and performance improvement
research; decision analysis

are examples of __ (causes/purposes/reasons) of pt records

A

purposes

39
Q

education
credentialing, regulation, legislation
reimbursement
legal and historical documentation

are also examples of __ of pt records

A

purposes

40
Q

components of a medical record include (accdifppm):

A

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

41
Q

electronic medical records are a __ and __ database

A

uniform; standardized

42
Q

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

A

true

43
Q

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

A

true

44
Q

someone can chart under your name. true or false.

A

false. no one should chart under your name