LEGAL PROTECTION OF NURSING SERVICE

Janna Kristine F. Yosores BSN 4L

a) To identify the different legal protections of nursing service; b) to define each of the ff: - testament - written and informed consent - incident report - documentation; and

c) to determine the different guidelines for informed consent and

documentation.

MEDICAL RECORDS

One source of information that people seek to help them make decisions about their health care is their testaments or medical records.

Nurses have a legal responsibility for accurately recording

appropriate information in the clients medical record. The

alteration of this can cause license suspension or revocation.

 in law, voluntary agreement with an action proposed by another. Consent is an act of reason; the person giving consent must be of sufficient mental capacity and be in possession of all essential information in order to give valid consent. A person who is an infant, is mentally incompetent, or is under the influence of drugs is

incapable of giving consent. Consent must also be free of coercion

or fraud.

 consent of a patient or other recipient of services based on the principles of autonomy and privacy; this has become the requirement at the center of morally valid decision making in health care and research. Many nurses erroneously believe that they have obtained informed consent when they witness a patients signature on a consent form of a surgery or procedure.

GUIDELINES FOR INFORMED CONSENT

The person(s) giving consent must fully

comprehend:
The procedure to be performed The risks involved

Expected or desired outcomes

Expected complications or side effects that may occur as a result of treatment

Alternative treatments that are available

 Consent may be given by: A competent adult A legal guardian or individual holding durable power of attorney An emancipated or married minor Parent of a minor child Court order.

INCIDENT REPORT
Incident reports are records of unusual or unexpected incidents that occur in the course of a clients treatment.

Incident reports are inadvertently disclosed to the

plaintiff are no longer considered confidential and can

be subpoenaed in court.

Thus, a copy of an I.R. should not be left on a chart.

DOCUMENTATION
Documentation is any written or electronically generated

information about a client that describes the care or

service provided to that client. Health records may be paper documents or electronic documents, such as

electronic medical records, faxes, e-mails, audio or

video tapes and images.

 A document or chart must be written in F-L-A-T to protect nurses to be repeated to the jury for several times.

F: A document should be FACTUAL, what you see, not what you get.

L: A document should be LEGIBLE, with no erasures. Corrections should be made as you have been taught. With a single line drawn through the error and initialled.

 A: A document should be ACCURATE and complete. What color

was the drainage? How many times was the practitioner notified of changes.

T: A document should be TIMELY, completed as soon after the occurrence as possible. Late entries should be avoided or kept minimum.

 Three common documentation forms - focus charting, SOAP/SOAPIER and narrative documentation are described in the following sections. Any of these methods may be used to document on an inclusion or exception basis. 1. FOCUS CHARTING 2. SOAPIE CHARTING 3. NARRATIVE CHARTING

FOCUS CHARTING
With this method of documentation, the nurse identifies a focus based on client concerns or behaviours determined during the assessment. the assessment of client status, the interventions carried out and the impact of the interventions on client outcomes are organized under the headings of data, action and response.

 Data: Subjective and/or objective information that supports the stated focus or describes the client status at the time of a significant event or intervention.

Action: Completed or planned nursing interventions based on the nurses assessment of the clients status.

Response: Description of the impact of the interventions on client outcomes.

SOAP/SOAPIE(R) CHARTING
SOAP/SOAPIER charting is a problem-oriented approach to documentation. S = subjective data (e.g., how does the client feel?) O = objective data (e.g., results of the physical exam, relevant vital signs) A = assessment (e.g., what is the clients status?) P = plan (e.g., does the plan stay the same? is a change needed?) I = intervention (e.g., what occurred? what did the nurse do?) E = evaluation (e.g., what is the client outcome following the intervention?) R = revision (e.g., what changes are needed to the care plan?)

NARRATIVE CHARTING
Narrative charting is a method in which nursing interventions and the impact of these interventions on client outcomes are recorded in chronological order covering a specific time frame. Data is recorded in the progress notes, often without an organizing framework. Narrative charting may stand alone or it may be complemented by other tools, such as flow sheets and checklists.

LEGAL GUIDELINES IN DOCUMENTATION

1. DOCUMENT FACT
Fact is what the nurse saw, heard or did in relation to the patient's care and condition. This is what should be documented. Nurses and midwives should avoid non-committal documentation. An extension of this principle is that nurses should write health care records objectively. Irrespective of where the nurse or midwife is recording information, that is the nursing notes, incident forms or statements, documentation should always remain factual and objective and not subjective or emotive.

2. Document all relevant information

This will be dictated by consideration of the individual circumstances

of each patient. Nurses' and midwives' documentation should be

made with respect to the total condition of the patient, not just a clinical specialty. In particular, nurses and midwives should document any change in the condition of the patient and who was notified of such a change.

3. Document contemporaneously
Nurses and midwives should record entries in the

patient's notes as soon as possible after the events to

which reference is being made have occurred, with the date and time for each entry recorded. All entries should also include the author's signature, printed name and designation. This clearly indicates when the record was made and by whom and ensures more reliable documentation. Nurses and midwives should never predate or pre-time any entry on a patient's chart. If an observation is made or a medication is given at a certain time, that time should be recorded on the chart.

4. Maintain the integrity of documentation

This principle refers to the requirement to preserve all that is

recorded in a patient's record, even if an error is made. Nurses and

midwives should not attempt to change or delete errors made in the patient's notes. An attempt to change or delete an entry could be interpreted as an attempt to cover up events or mislead others. The error should be left so that it is legible, with a single line through it, and initialled. The correct entry should then be recorded on the next line or column. Documentation should not include breaks between entries; this ensures that information cannot be added after the fact.

THE END THANKS FOR LISTENING! =)