Download 06. Legal Implications in Nursing Documentation

LEGAL IMPLICATIONS IN
NURSING.
DOCUMENTATION
Legal Terms
• Negligence
▫ A general term that refers to conduct that does not show due
care
▫ Occurs when someone fails to do something that a
reasonably prudent person would do in a similar situation
▫ Four essential characteristics
 Duty
 Breach of duty
 Harm
 Causation
Legal Terms
• Duty
▫ Duty of a professional toward an individual
▫ That duty is established when the nurse patient relationship
is started
• Breach of duty
▫ Nursing care fell below acceptable standards or the nurse
was negligent
Legal Terms
• Harm
▫ The patient has been injured in some way
• Causation
▫ The breach of duty caused the harm
Legal Terms
• Malpractice
▫ Specific type of negligence
▫ Applied to professionals who fail to follow a standard of
care prevalent for the profession and thereby harms another
person
▫ Ranges from being negligent when caring for a patient to
betraying a confidence
Legal Terms
• Standard of Care
▫ Level of care a reasonably prudent nurse would have
maintained
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Standards of care change with each new medical advance
Must keep up with the latest information in your field
Must read journals, attend conferences
Be familiar with the policy and procedure manuals and
clinical pathways in your facility
Legal Terms
• Liability
▫ And obligation or debt that can be enforced by law
▫ In cases of malpractice a person found guilty of a tort is
considered legally liable, or legally responsible for the
outcome
Liability
• Common sources of liability
▫ Most malpractice claims come from routine functions
 Falls
 Medication errors
 Burns
 Failure to observe
 Failure to notify MD
 MDs failure to respond
 Violation of policies and procedures
 Defective equipment
 Improper pt teaching
Liability
• Falls
▫ Identify pt who is at risk for a fall and take action
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Blind
Elderly
Sedated
Dizzy
Confused
Immediately post-op
Liability
• Document use of
▫ Restraints
▫ Side rails
▫ Monitoring of pt
• Use care with restraints
▫ Side rails are considered a restraint
▫ May be chemical or physical
▫ Should use the least restrictive method
▫ Continually monitor the pt
▫ Careful documentation
Liability
• Medication errors
▫ Perhaps 98,000 Americans dies each year from med errors
▫ Remember the five rights
 Right patient, drug, dose, time, route
 Check the med label three times before administering the
med
 Know the correct dose
 Know the correct route
 Know the potential side effects
 Clarify any order with the physician who ordered the drug
Liability
• Burns
▫ Hot water
▫ Heating pads
▫ Heating lamps
▫ Sits bath
Liability
• Failure to observe
▫ Keep monitors on the pt
▫ Monitor vital signs after administration of pain meds
▫ Monitor pt closely and report any complications
Liability
• Failure to notify the physician
▫ Must communicate any pertinent information to the pt’s MD
in a timely manner
▫ Must speak with MD, not leave messages
▫ Should go up the chain of command if unable to get MD
▫ Notify MD if there is a change in the pt’s condition
Liability
• Physician's failure to respond
▫ If you feel that the MD does not respond in a satisfactory
manner, must notify the supervisor, hospital administrator,
or medical director
Liability
• Violation of policies and
procedures
▫ You are responsible for
knowing them
• Defective equipment
▫ Must select the appropriate
equipment for a particular pt or
procedure
▫ Maintain that equipment
▫ Use the equipment properly
▫ Report any problems
immediately
Liability
• Improper patient teaching
▫ Liable for what you teach or fail to teach
▫ Give written instructions to reinforce the verbal instructions
▫ Document teaching in the chart
▫ Must provide it in the patient’s primary language
Incident Reports
• Allows hospital administration to identify problems within the
hospital system
• Alert administration of an event that may end up in a lawsuit
• Important to fill out one to identify problematic situations and
create a safe environment
• Keep statements factual, objective, do not draw conclusions
• Do not mention incident report in charting
• May or may not be allowed into court
When you are new to the unit:
• Review the key points of the information presented to you in
orientation. Ask yourself how practices in this organization
differ from your previous position. Validate your assumptions
about whether previous expectations apply in this setting.
During your first shift on the unit:
• Make a point of reviewing two or more medical records. Pay
particular attention to nursing documentation and flow sheets.
Are the instructions clear? If not, ask a staff member to clarify.
If and when you float:
• Make it a priority to familiarize yourself with documentation
expectations unique to the unit to which you have floated.
Perioperative Services: Pre- and Intra-Operative
Each phase of the surgical process has specific documentation
implications:
Intra-operative:
Pre-operative:
• Comprehensive assessment of the
patient’s systems
• The patient’s understanding of
and consent to the procedure to be
performed
• • “Time Out””
• • Equipment checks
• • Confirmation of the
identification of the patient and
surgical site
• • Positioning of the patient
• • Identification of anesthesia
reactions
• • Measures to prevent burns,
injuries from pressure, and other
injuries
• • Sponge count
Documenting Verbal Orders
• Sign and initial your notes.
• Record the order in the patient’s record
as soon as reasonably possible. Note date
and time and then the order verbatim.
Write the prescriber’s full name and sign
your name. If another nurse witnesses
(that is actually hears) the order, that
nurse should sign as well.
• Label the order “T.O.” for telephone
order or “V.O.” for verbal order or as
policy dictates. Avoid the use of “P.O.”
to represent “phone order” since that
designation may be confused with PO
meaning “per os” or orally.
• Draw lines through any blank spaces.
• Encourage the use of fax in lieu of telephone orders to
provide a written record.
• Comply with prohibitions on verbal orders, such as:
• Most organizational policies prohibit verbal or telephone
orders for do not resuscitate orders (DNR).
• TJC standards prohibit accepting orders via voice mail.
Documenting Pain Assessment
• Your entries in the patient’s record must give evidence that you
have met the standards for pain management, including evidence
of:
• Assessment and effective management of pain in every patient.
Assess cultural factors that may affect response to pain.
• The patient’s involvement in managing his pain – including
patient’s self-assessment of intensity of pain and pain goals.
• Initial and ongoing reassessment of pain:
• Intensity per pain scale, location, character, frequency, pattern,
onset and duration, alleviating and aggravating factors, current
pain interventions and effectiveness, and acceptable level of pain.
• The patient’s pain management goals.
• Pain management history, including effects of pain in the
patient’s daily life, such as upon eating, walking, and sleeping.
• Appropriate assessment for patients who are children or who are
unable to communicate verbally.
• Pain assessment at least as frequently as other vital signs.
• Assessment and monitoring during the post-procedure period.
Documenting Pain Management
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Date, time
Patient behavior
Vital signs, including pain scale rating
Intervention: position and other non-pharmaceutical relief
measures
Pain scale rating after intervention and reassessment within
thirty to sixty minutes, depending on the medication and
administration route
Education provided to patients and families regarding pain
including:mportance of pain management
Reporting pain
Assessment process
• Risk for pain
• Pain management methods, limitations and side effects – if
appropriate, including alternative and complementary
methods, such as guided imagery, heat, cold, and massage
therapy
• Patient’s role in process
• Discharge planning which identifies and addresses patients’
pain management needs. (for the patient at end-of-life,
documentation reflecting sensitivity to comfort, including
physical, psycho-social/emotional, and spiritual comfort)
• The patient’s response to interventions, and modifications of
the plan if needed
Medications
• Follow organizational policy scrupulously regarding
documentation of medications.
• Use only organization-approved symbols and codes on the
MAR.
• Document patient response to medications.
• Document your patient teaching related to medications.
• Never document medications as given before you administer
them. Charting medications not givenis criminal as well as
unprofessional
• If for any reason, you use incorrect or unusual technique in
administering a medication, document the situation, follow-up
assessment, and any necessary intervention.
Nurses’ actions which have led to medication
errors include:
• Failure to check the medication administration record (MAR)
against the order
• Use of banned abbreviations
• Leading to administration of a wrong drug or dosage
• Mistaken interpretation of illegible penmanship
• Failure to obtain clarification as needed, and transcription
errors
• Failure to document a dose, leading to a duplicate dose when
another nurse administers a dose (more likely at breaks or
mealtimes, when a second nurse may temporarily assume the
patient’s care)