Legal Issues Documentation Flashcards
Describe nurse practice act
Differ by state
Practicing beyond your scope is a violation
What are the two types of credentials
Licensure: passing NCLEX
Certifications: SANE nurse/ validates specialty knowledge
Torte
Wrongful acts made against a person
Describe these terms:
Assault
Battery
Fraud
Invasion of privacy
False imprisonment
Verbal
Physical
Stealing money or pretending to be a nurse or charting something wrong
HIPPA
restraints
Negligence
Breach of duty care
Not doing hourly rounds
What is the key factor with documentation
If it wasn’t documented, it was not done
Describe examples of permitted disclosure
CDC telling people they were in contact but not using name
Child or domestic abuse case
Organ donations
Funeral arrangements
What are some guidelines for documenting
Don’t chart in advance
Don’t wait until the end of shift
Military time
Don’t leave a blank space
Significance of computerized records
Don’t trade passwords
Log in and out
When are verbal orders used
In urgent situations
PIE
Problem intervention evaluation
SOAP
Subjective objective assessment plan
DAR
Data action response
What is the JC patient safety goal
Improve effective communication
What type of reports should be done?
Changing shifts
Face to face
Written
Bedside rounds
