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!
=)