Janna Kristine F. YosoresJanna Kristine F. Yosores

BSN 4LBSN 4L

LEGAL PROTECTION OF LEGAL PROTECTION OF NURSING SERVICENURSING SERVICE

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 client’s 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

patient’s 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 client’s 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.

GUIDELINES FOR GOOD

DOCUMENTATION• 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.

FORMS OF NURSING

DOCUMENTATION

 • 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

F O C U S C H A R T I N G

• 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

nurse’s assessment of the client’s status.

• Response: Description of the impact of the interventions on client

outcomes.

S O A P / S O A P I E ( R ) C H A R T I N G

• 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 client’s 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?)

N A R R A T I V E C H A R T I N G

• 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 pre-date 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 ENDTHANKS FOR LISTENING!

=)