Legal Implications Document A Schneider PDF
Legal Implications Document A Schneider PDF
Issues in Nursing
Alexa Schneider, PhD, PsyD, RN, FNP, LNCC, NY-SAFE
Objectives
Describe how current and future healthcare trends will impact
legal and ethical issues in nursing, patient care technicians,
social workers, and office personal.
School:
Learn to obtain license
After school:
Learn to maintain/protect/keep license
Medications
Giving meds on time – not when convenient for nurse
(Heparin, Antibiotics, and etc.) Giving med and
scanning med at a later time.
5 rights
Cases
Failure to follow policy
Failure to raise bedrails
Criteria for Incident Reports
Should be completed for any usual, unexpected, or
unanticipated occurrences, and for any event which has
or may have an adverse patient outcome.
Patient falls
Medication error
Loss of valuables, belongings
Equipment malfunction
Property damage
Near misses
Incident reports
Be Objective
Do not blame or admit liability
What did you do?
Do not include names/addresses of witnesses
Document time/name of medical provider
Do not file in chart
Do not write “incident report made”
Proper handoff
communication
Required to properly “handoff ” your patients to another
qualified professional.
Tool SBAR:
S=Situation: patient name, DOB, & medical provider
B=background: date of admission, diagnosis & current
condition including test results
A=Assessment: summary of recent events/changes in
condition or treatment and any anticipated changes in condition
or treatment.
R=Recommendations: state your nursing recommendations
with any new treatment in the plan of care by the medical
provider.
Abandonment
Diversion
Social Media
Facebook
Twitter
Texts
E-mails
Hospital scenario
Date and time of call
Provider name
Client’s chief complaint
Information you provided
Orders received/not received
Nurses who disagree with a provider’s order should not carry out an
obviously erroneous error.
Pitfalls for Staff
Red Flag Complaints
Documentation
Documentation
Written evidence of interaction between and among health professionals,
patients, and their families; the administration of procedures, treatments, and
diagnostic tests; the patient’s response to them and education of the family
support unit.
Major purpose of medical record is to document the care given to the patient.
Nurse Practice Act states the general duty is to “record pertinent information
including the response to interventions”.
Also a legal document. Courts have issued a warning to nurses & medical
personnel that the availability of accurate medical records is NOT a technicality
but IS a legal requirement.
Chart is a persuasive witness because it’s a description of the facts at the time.
Client/family education/instructions
Documentation Don’ts
Complaints
Opinions
Altering the record
Chart ahead
Staffing problems
Staff conflicts
Leave empty lines/spaces
Make reference to incident reports
Documentation
The following can lead to state licensing board
suspending or revoking nurse license:
Failure to document entries in patient record
Falsification of patient record
Making incorrect entries
Devastating Injuries
Unreasonable Expectations
Unexpected Results
Extent of Suits
Sued the most
Legal Role of the Nurse
Provider of service
Ensure that client receives competent, safe, & holistic care
Render care by “standards of reasonable, prudent person”
Supervise/evaluate that which has been delegated
Documentation of care
Maintain clinical competency
Legal Negligence in Nursing
Failure to use equipment in a responsible manner
Failure to assess and monitor and failure to
communicate
Failure to document
Failure to act as a patient advocate
Performing nursing procedures incorrectly
Failing to take appropriate precautions
Responsible &
Accountable
You are responsible and accountable for your actions
based on:
Your clinical training
Your title
Scope of practice
Standard of care guidelines
Policies and procedures of your health care facility
Ways to Avoid
Malpractice
Know your own strengths and weaknesses
Evaluate your assignment
Delegate carefully
Exercise caution when assisting procedures
Document the use of restraints
Take steps to prevent falls
Comply with laws about advance directives
Follow hospital policies and procedures
Keep policies and procedures up to date
Provide a safe environment
ELEMENTS OF NEGLIGENCE
Deviation from the standard of care that results in harm to the patient
4 elements of negligence
BEHAVIORAL
Includes unprofessional, unethical, or criminal conduct
MEDICAL
Conditions which permanently impede or preclude a provider
from safely practicing medicine
Professional Misconduct
Violating any guidelines set forth by your state nursing board
places you at risk of being charged with professional
misconduct.
Obtaining license fraudulently
Practicing while impaired by ETOH, drugs, physical or mental
disability.
Habitual drunk or dependent on narcotics and other drugs with
similar affects
Refusing to provide professional service to a person based on
race, creed, color, or national origin
Practicing beyond authorized scope, with gross incompetence,
with gross negligence on a particular occasion or negligence or
incompetence on more than one occasion.
Maintaining License & a
Valid Registration Certificate
Professional license is “valid for life unless revoked or
surrendered for professional misconduct.”
It’s your obligation & responsibility to be mindful of the
following when it comes to maintaining your registration:
Expiration date. If expired do not practice until renewed.
Report name or address change to licensing agency for future
renewals.
Answer all questions pertaining to both criminal convictions
& terminations of employment truthfully.
Practice within your scope of practice and standard of care
guidelines.
Code of Ethics
Code of ethics defines the moral principles that govern how
you practice nursing and is the foundation on which nursing is
built.
Legal definition: “the minimum standards of appropriate
conduct within legal and regulatory parameters involving the
duty owed to your patient and other members of your
profession.”
Submitting work vouchers for home care visits not made
Breach of confidentiality
Fraud
Refusing to provide care for patient of specific cultural origin
Grounds for Suspension &
Revocation of License
Incompetent nursing practice
Professional misconduct
Conviction of a crime (Homicide; theft; manslaughter; illegible possession of controlled substance; sexual
assault; arson; DUI)