Week 8 - Documentation Flashcards
Most credible evidence in legal proceedings
The medical record
Negligence
Failure to use such care as a reasonably prudent and careful person would under similar circumstances
Time limit for lawsuits in healthcare
2 years unless a child is involved
Extensions may be granted
4 points must be proven for a lawsuit to proceed
- legal obligation to provide care
- breach in standard of care (BCCNM, facility, practice guidelines, etc)
- an injury must have occurred
- the injury was reasonably foreseeable occurrence as a result of breach in standard of care
Common nursing issues involved in negligence (5)
- communication
- assessment
- medications
- infection control
- equipment
Documentation is considered:
The last part of providing care
Not charted, not done
What gets nurses into trouble (8)
Failing to record pertinent health/drug info
Failing to record nursing actions
Failing to record administration of meds
Recording in the wrong chart
Failing to document a D/C med
Failing too record drug reactions or changes in patient condition
Transcribing orders improperly
Writing illegible or incomplete orders
Best things to keep yourself out of trouble
Documentation
- be thorough
Not optional
You will be judged on how you document
Keep documenting until situation is resolved
When in doubt, document
Incident reports are used for…
Internal identification and tracking of issues
Does not go in you employee file
DO NOT MENTION COMPLETION OF INCIDENT REPORT IN CHART
Usual components of an incident report
People involved
Description
Equipment involved
Injury if any
Actions taken
Notification of others
Actions take to resolve the issue
Few last notes on incident reports
Must be objective
Priority is safety
Sent to supervisors, doesn’t go in chart
