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law and health care Flashcards

1
Q

use of restraints

A

physical and chemical, ech facility needs a policy about restraint usage and situations when restraints can be used

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2
Q

patient self-discharge

A

a patient at any time– who is capable of making decision– is allowed to refuse care and leave *form

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3
Q

good samaritan law

A

stop and help someone with your abilities as long as your intent was to help someone you cannot be sued

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4
Q

whistleblower

A

laws that provide protection for whistleblowers so that they feel safe to come forward to report any wrong doings or anything they feel is unsafe care

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5
Q

consent

A

permission for something to happen or agreement to do something, each prov/ ter has its own legislation regarding consent

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6
Q

informed consent

A

consent to…
accept the treatment, desired outcomes, foreseeable risks,
aware of available options

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7
Q

voluntary consent

A

must not feel pressure, right to refuse at any time

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8
Q

criteria for consent

A

informed and voluntary

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9
Q

types of consent

A

express, written, oral, implied, in an emergency

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10
Q

express consent

A

can be written or oral, indicates clear choice of patient , usually requires patient to be fully informed

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11
Q

written consent

A

all major procedures, surgeries, medical interventions require written consent, ideally the patient should understnad the procedure, having signed the consent form may not hold up in court, if there is conflicting evidence, most need to be signed, dated and witnessed. witness needs to be comfortable that the client understands

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12
Q

oral consent

A

equally binding as written, spoken word in person or phone, some facilities require two HCP to validate telephone consent; protocols may vary, oral consent should be clearly documented in chart

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13
Q

implied consent

A

when someone seeks treatment at a doctors office or ER, by allowing themselves to be admitted, consent is implied for certain interventions: also includes sharing of health information with other care providers as need basis.

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14
Q

in an emergency consent

A

HCP should obtain consent in an emergency situation if possible if there is a barrier to obtaining consent and the HCP feels that delaying action may result in serious consequences, treatment may be provided without consent. important to document the situation clearly and concisely

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15
Q

who can give consent

A

competent person, legal representative (next of kin), legal power of attorney, when someone is legally assigned to make decisions

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16
Q

steps to obtaining consent

A
  1. assess capacity
  2. provide emergency treatment
  3. inform client that substitute decision maker will decide
  4. identify substitute decision maker
  5. obtain consent from substitute decision maker
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17
Q

Step one: assessing capacity

A

does hcp feel certain that the individual is able to understand and make decisions, age of consent (no min age except in quebec, if they understand treatment and potential risk able to decide), role of evaluator (determine capacity), role of capacity assessor (conducts assessment on individual who needs decisions made on their behalf), incapable person (consent is obtained from the highest ranked available substitute decision maker)

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18
Q

step 2 provide emergency treatment or crisis admission: treatment in an emergency can be provided immediately:

A
  1. if person capable of giving consent does so,
  2. in a situation where communication cannot take place or reasonable efforts to overcome barriers but delay may cause further harm
  3. person is incapable with respect to making treatment decisions but sub decision maker consents
  4. person is incapable with respect to treatment , sub decision maker not available
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19
Q

step 2 provide emergency treatment or crisis admission: crisis admission

A

person who has deemed capable require immediate admission as a response to crisis
it is not reasonably possible to obtain consent on the incapable persons behalf

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20
Q

step 3: inform client substitute decision maker will make decisions

A

ensure that the patient knows their rights, who will make decision for them

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21
Q

Step 4: identify substitute decision maker

A

a spouse, partner or relative who is present when the treatment is proposed may make decision unless a specially appointed substitute is available, a spouse, partner or relative with a higher priority and willing to assume the responsibility to give or refuse consent
(HCP can rely on persons statement, documentation is not required)

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22
Q

step 5: obtain consent from substitute

A

substitute is to make decision based on what the incapable person would want, if unsure make decision in best interest of incapable person

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23
Q

consent for deceased organ donation

A

prov/ter legislation, most 16 years or older, donor card, driver license, medicare card (nova scotia automatic donation)

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24
Q

the health record

A

variations depending on institution/ organization
contains information about individuals health and services provided
HCP can access health record only if part of circle of care
hospitals and long term care charts contain different sections to organize information

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25
accurate recording/ documenting
legislation requires documentation anything entered needs to be considered as having potential to become evidence (your memory if ever call to testify) communication with team members (detailed, clear and concise) nurses cannot diagnose ensure no labels are used
26
methods of documentation
focus charting narrative charting my exception
27
focus charting
highlight the topic and document only things related to that topic
28
narrative
more like a story, all details not just important topic
29
charting by exception
only document something that is abnormal
30
purpose of documenting
identify the care and services a client requires or care that was provided inform quality improvement processes review client outcome information identify knowledge gaps valuable source of data collecting in health related research source of information is making funding and resource management legal investigations
31
health information
all jurisdictions have laws regarding health info and privacy agency that create the physical chart owns and maintains individuals health info belongs to them -physicians have 30 days to present written consent is required to share info individuals have the right to access their health info
32
clients right regarding health info
they cannot take the physical chart or amend it in any way, supervision is necessary, changes may be made upon agreement of provider, changes must be initialed and dated
33
storage and dispoal of health record
health records must be maintained if physician stops practicing, servers must be professionally wiped, paper documents shredded in confidential manner records must be safe and secure
34
records must be safe and secure
protected from fire, encrypted software and passwords access must be restricted to only those necessary electronic system must have audit trail responsibility to protect chart
35
privacy act 1983
limits private info collected by fed gov, restricts use and sharing ( even between fed gov departments), allows individuals to access their info
36
Personal Information Protection and Electronic Documents Act (PIPEDA)
personal information definition deals with info collected by private sector, protects personal information that is collected, used or disclosed, consent based legislation personal health info is usually legislated by prov/ ter as it is related to health care
37
consent based legislation
companies must provide individuals with consent form that fully discloses how personal information will be collected, stored and used
38
personal information
information about an identifiable individual
39
Personal Health Information Privacy and Access Act (PHIPAA)
nb provincial privacy act-- individuals have the right to their own info
40
confidentiality
HCP moral and legal obligation to maintain privacy of patient info, circle of care,
41
privacy
patients right for their health info to remain confidential, patient info can only be released with their consent
42
Circle of care
HCP directly involved in patient care
43
situations where HCP are obligated to release confidential info
some communicable diseases are to be reported to the public health individual has harmed or or is danger of harming themselves or others: abuse of vulnerable persons
44
breach of confidentiality
may result in lawsuit even if breach was not intentional
45
health informatics
use of information technology (including both hardware and software) in combination with information management concepts and methods to support the delivery of health care
46
nursing informatics
the practice and science of integrating nursing information and knowledge with technology to manage and integrate health information. The goal of nursing informatics is to improve the health of people and communities while reducing costs
47
consumer informatics
focus on information structures and processes that empower consumers to manage their own health-- for example health information literacy, consumer friendly language, personal health records and internet based strategies and resources
48
digital health
the use of information technology/ electronic communication tools, services and processes to deliver health care services or to facilitate better health
49
advantages of computerization
security, improved communication, real time access to information, legibility, standardization of info collected, data sets
50
disadvantages of computerization
security, cyberhackers, employees create risk for branch, labor intensive process for successful implementation
51
nurses role in digital health
documentation, communication, utilize digital health info to inform decisions, custodian of info, collab with IT regarding nursing specific needs and implementation of digital health solutions, utilize data for research to create nursing knowledge
52
information and communication technology skills (ICTS)
foundational skills expected of students entering university:...
53
nursing informatics entry level competencies
uses relevant information and knowledge to support the delivery of evidence informed patient care uses ICTs in accordance with professional and regulatory standards and workplace policies uses information and communication technologies in the delivery of patient/ client care
54
electronic medical record
owned by facility and organization, only available at that location, contain only information about services provided in this location
55
electronic health record
bigger picture (central database) may contain information from multiple sources (pharmacy, hospital, public health) may be accessed by HCP providing care Deemed more secure than paper More people involved leaves more opportunity for breach
56
canada health infoway
non profit organization that provides digital health solutions for canada goals to improve IT and connectivity across the health care system
57
recent canada health infoway projects
``` prescribe IT (collaboration with HEalth Canada, prov/ter organizations, improve pharmacy related connectedness with national system) ACCESS health (enhances patient accessibility to health information, patient centred care) ```
58
C-HOBIC
Canadian Health Outcomes for Better Information and Care
59
ICNP
International Classification for Nursing Process
60
SNOWMED-CT
Systemized Nomenclature of Medicine- clinical terms, consistent way to store and retrieve data

Cdn Health Care (4 decks)

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