Nursing Management and Leadership Modalities of Care PDF

NCM 118: NURSING MANAGEMENT AND LEADERSHIP MODALITIES OF CARE PRESENTED BY: Balicdang, Danilyn Marie E. Batil, Kaycee T. Bayacsan, Vivian C. Bumughawi, Mailyne Kim C. Dalope, Robin Wilfred Hans D. Duping, Reka Mae B....

NCM 118: NURSING MANAGEMENT AND LEADERSHIP MODALITIES OF CARE PRESENTED BY: Balicdang, Danilyn Marie E. Batil, Kaycee T. Bayacsan, Vivian C. Bumughawi, Mailyne Kim C. Dalope, Robin Wilfred Hans D. Duping, Reka Mae B. Ladip, Giann Kaye E. Pinos-an, Prejamin B. Salis, Vina M. Tanglod, Carcel M. Tukaki, Trixie L. Tuldague, Hannah Veah O.  MODALITIES OF CARE This response will delve into the various modalities of care employed in nursing, exploring the advantages, disadvantages and contemporary relevance. Nursing professionals must comprehend these different models to provide high-quality and patient-centered care while optimizing resource utilization and fostering professional satisfaction. It refers to the manner in which nursing care is organized and delivered depending on the: Philosophy of the organization Nurse staffing Client population 1. CASE METHOD/ TOTAL PATIENT CARE In the case method, the nurse cares for one patient whom the nurse cares for exclusively. The Case Method evolved into what we now call private duty nursing. It was the first type of nursing care delivery system. In Total Patient Care, the nurse is responsible for the total care of the patient during the nurse’s working shift. The RN is responsible for several patients. Advantages: Consistency in carrying out the nursing care plan Patient needs are quickly met as high number of RN hours are spent on the patient Relationship based on trust is developed between the RN and the patient’s family Disadvantage: It can be very costly Model:  2. PRIMARY NURSING A primary nurse is assigned responsibility for a patient throughout their hospital stay, offering personalized and continuous care where the primary nurse accepts total 24-hour responsibility for the patient’s nursing care. Primary nursing in the inpatient setting - Also known as relationship-based nursing - The primary nurse assumes 24-hour responsibility for planning the care of one or more patients from admission or the start of treatment to discharge or the treatment’s end. - During work hours, the primary nurse provides total direct care for that patient. When not in duty,associate nurses follows the care plan established by the primary nurse. - Originally, primary nursing was designed for use in hospitals, but it can lend itself well to home health nursing, hospice nursing, and other health-care delivery enterprises as well. - Integral responsibility is to establish clear communication among the patient, physician, associate nurses, and other team members. - Uses some of the concepts of total patient care and brings the RN back to the bedside to provide clinical care Holistic, high-quality patient care given through the combination of clear interdisciplinary group communication and consistent, direct patient’s care by relatively few nursing staff. - Holistic, high-quality patient care given through the combination of clear interdisciplinary group communication and consistent, direct patient’s care by relatively few nursing staff. Registered Nurse Primary Care Coordinators in Patient-Centered Medical Homes - The patient- centered medical homes (PCMH) delivers cost effective, primary care, utilizing care coordination ensuring high value and improving health outcomes. RNs are increasingly serving as the front line primary care leaders in PCMHs alongside physicians and advanced practice nurses. - In this role, RNs engage patients and families in care coordination, enhance care transition,manage complex chronic patient care plans, and promote preventive care services to empower patient self-care. - The seven domains required for primary care coordination: 1. Population health management:A change from a focus on a single provider caring for the health and well-being of an individual patient to a focus on a health-care team managing the health of a panel of patients. 2. Comprehensive assessment and care planning: A thorough knowledge of chronic disease management and evidence-based guidelines and protocols, especially for chronic heart failure (CHF), chronic obstructive pulmonary disorder (COPD), diabetes, and depression. 3. Interpersonal communication: Includes the ability to use different communication styles, including active listening, to counsel, interview, resolve conflict, build relationships, and develop effective interdisciplinary teams. 4. Education/coaching:A working knowledge of adult education principles and learning techniques, readiness to change, and identification of necessary person-centered components for a self-management plan.  5. Health insurance and benefits: Current knowledge of health insurance, managed care, and other payer sources and benefits. 6. Community resources:A thorough familiarity of public and private community-based providers, services, and support available in the local geographical area. 7. Research and evaluation: A basic understanding of research and evaluation techniques to assist in quality improvement of care and interpretation of program outcomes. Interprofessional Primary health care teams - Primary health-care teams (PHCTs) are interprofessional teams that include, but are not limited to, physicians, nurse practitioners, nurses, physical therapists, occupational therapists, and social workers who work collaboratively to deliver coordinated patient care. - Interprofessional team brings together differing viewpoints, life experiences and knowledge of evidence based practices, determining what knowledge is most important in caring for the patient. Advantages: - Patient satisfaction- patients benefit from a consistent and personalized approach to care, potentially leading to increased satisfaction and improved outcomes. - Professional fulfilment- primary nurses have greater autonomy and responsibility leading to increased professional fulfilment and a sense of ownership over patient care. Disadvantages: - Limited reach- this model may limit the nurses ability to share their expertise with a wider range of patients. - intimidation - less experienced nurses may feel intimidated by the level of responsibility and autonomy required. Model:  3. TEAM NURSING It was developed in the 1950s and aims to address the fragmentation inherent in functional nursing. This model involves a team of nurses led by a registered nurse, with each team member responsible for a group of patients. The team leader coordinates care, assigns tasks based on individual skills and ensures accountability for the overall care. - As the team leader, the nurse is responsible for knowing the condition and needs of all the patients assigned to the team and for planning individual care. - The Team Leader has a core of staff reporting to her, and together they work to disseminate the care activities. - Duties of team leaders: Assisting team members Giving direct personal care to patient Teaching and coordinating patient activities. Advantages: - Maximized skills - team members can utilize their unique skills and expertise, potentially leading to higher job satisfaction - Accessibility - patients have access to the team leader, who can provide immediate support and facilitate communication with other healthcare providers. Disadvantages: - Escalating Demands of Leadership - increase responsibility on team leaders to both take care of patients and supervise team members. However , this issue can be resolved by encouraging nursing staff to be more independent and develop self-education and professional growth. - Continuity - patient care may suffer from lack of continuity, as a team leader and members may change shifts, leading to inconsistent care delivery. Model: 4. MODULAR NURSING - An adaptation of team nursing wherein a group of staff is assigned to a group of patients in a close proximity. - A consistent group of caregivers are assigned to a specific set of patients within a specific area of a nursing unit. - The goal is to make patient care less fragmented. - The group of staff is usually a mini-team, composed of two or three members (licensed practical nurse and nursing assistants) with at least one registered nurse (team leader). - The members are called care pairs and the patient care units are divided into modules or districts. Advantages: - Useful when there are few registered nurses. - The registered nurses have more time to plan their care. - Continuity of patient care is improved as the team of caregivers grows more familiar with their patients and their unit. - The smaller, more focused patient care teams can result in higher levels of accountability for individual team members. Disadvantages: - Requires a high level of nursing leadership. - Paraprofessionals do technical aspects of nursing care. Example: - The care pairs are assigned to a row of consecutive patient rooms in a hallway. Model: REFERENCES: Modalities of Care. (n. d). Scribd. https://www.scribd.com/presentation/638039237/MODALITIES-OF-CARE Modular Nursing – Optimizing RN involvement in patient care and management. (n.d.). Default. https://www.healthstream.com/resource/blog/modular-nursing-optimizing-rn-involvement-in-p atient-care-and-management Sportsman, S. (n.d.). Care Delivery Strategies. Nurse Key. https://nursekey.com/care-delivery-strategies/ Studocu. (n.d.). Modalities of Nursing Car1 - Modalities of Nursing Care This refers to the manner in which nursing - Studocu. https://www.studocu.com/row/document/moi-university/nursing/modalities-of-nursing-car1/37 268520?fbclid=IwY2xjawFm54tleHRuA2FlbQIxMAABHfE4x-xdMe7C5AwIQzAwwxGCvlfLdO kn2jeAnVxXm5H13FrhM3z1tsj6pg_aem_dWZLx1X0ues7l58KUJruFg What are Nurse Staffing Models? (Video). (2024, August 30). |. https://www.mometrix.com/academy/nurse-staffing-models/#:~:text=Modular%20nursing%20 is%20considered%20an,patient%20rooms%20in%20a%20hallway.  NCM 118: NURSING LEADERSHIP AND MANAGEMENT MODALITIES OF CARE Group 3 Abando, Kate Justine Balanggoy, Julisa Bato, Joyce Ann Baucas, Jean Nichole Casulla, Ericka Ebbes, Davys Lag-ao, Reychiel Langit, Jericko Oaquin Maliones, Heather Rhyza Paleng, Alyze Grace Ramos, Chaya Rol, Raizel Janine 1. FUNCTIONAL NURSING (Task Nursing) - History: Evolved during the mid-1940’s due to the loss of RNs who left home to serve in the armed forces during the Second World War. Prior to the war, RNs comprised the majority of Hospital staffing. Because of the lack of nurses to provide care at home, hospitals used more LPNs (licensed practical nurse) or licensed vocational nurses (LVNs) and UAP (unlicensed assistive personnel) to care for clients. - Description: Is a task-oriented method wherein a particular nursing function is assigned to a specific member. Work assignments by functions or tasks such as giving medications, changing of dressings, giving TSB’s or taking vital signs. - The key idea was for nurses to be assigned to tasks, not to patients Structural Diagram of Functional Nursing - ADVANTAGES: 1. A very efficient way to deliver care 2. Could accomplish a lot of tasks in a small amount of time 3. Staff members do only what they are capable of doing 4. Least costly as fewer RNs are required 5. No role confusion - DISADVANTAGES: 1. Care of patients become fragmented and depersonalized 2. Patients do not have one identifiable nurse 3. Very narrow scope of practice for RNs 4. Leads to patient and nurse dissatisfaction 2. NURSING CASE MANAGEMENT - A collaborative process of assessment, planning facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost effective outcomes. (Case Management Society of America). - Case managers serve as patient advocates who support, guide, and coordinate care for patients, families, and caregivers. They help patients access community resources, learn about their  medication regimen and treatment plan, and ensure that they have recommended tests and procedures. - Nurses address each patient individually, identifying the most cost-effective providers, treatments, and care settings possible. - Acute care case management - integrates utilization management and discharge planning functions and may be unit based, assigned by patient, disease based, or primary nurse case manager. - Case managers often manage care using the following to plan patient care: A. Critical pathways - Also called as clinical pathways. - A strategy for assessing, implementing, and evaluating the cost-effectiveness of patient care. - Reflect relatively standardized predictions of patients’ progress for a specific diagnosis or procedure. - Advantage: provide some means of standardizing care for patients with similar diagnoses. - Disadvantage: Unique patient progress that differs from the critical pathway prompts a variance analysis. B. Multidisciplinary action plans (MAPs) - a combination of a critical pathway and a nursing care plan. - It indicates times when nursing interventions should occur. - It facilitates expected outcomes. C. Disease Management - Also known as population-based health care and continuous health improvement, is a comprehensive, integrated approach to the care and reimbursement of high-cost, chronic illnesses. - The goal of DM is to address illnesses or conditions with maximum efficiency across treatment settings regardless of typical reimbursement patterns. - Disease Management programs reduced hospitalization and health-care expenditures for individuals with asthma, cardiovascular disease, congestive heart failure, depression, musculoskeletal problems, low back pain, and migraines. - Disease Management did not have any effect for individuals with diabetes, arthritis, or osteoporosis. This can be attributed to several key rationales: 1. One-Size-Fits-All Approach: Many disease management programs are designed generically, without accounting for the unique needs and circumstances of each patient. This can lead to interventions that do not resonate with or effectively address the specific challenges faced by individuals with these conditions. 2. Complexity of Chronic Conditions: Chronic diseases such as diabetes, arthritis, and osteoporosis often interact with each other and can complicate treatment. Programs that focus narrowly on one condition may neglect how these diseases influence each other, leading to ineffective management. 3. Variability in Disease Severity: The severity and progression of these conditions can vary widely among individuals. A standardized approach may not effectively address the needs of those with more severe or complex cases. - Focus is on “covered lives” or populations of patients, rather than on the individual patient. - Goal is to service the optimal number of covered lives required to reach operational and economic efficiency.  - Common Features of Disease Management Programs: 1. Provide a comprehensive, integrated approach to the care and reimbursement of common, high-cost, chronic illnesses. 2. Focus on prevention as well as early disease detection and intervention to avoid costly acute episodes but provide comprehensive care and reimbursement. 3. Target population groups (population based) rather than individuals. 4. Employ a multidisciplinary health-care team, including specialists. 5. Use standardized clinical guidelines—clinical pathways reflecting best practice research to guide providers. 6. Use integrated data management systems to track patient progress across care settings and allow continuous and ongoing improvement of treatment algorithms. 7. Frequently employ professional nurses in the role of case manager or program coordinator. ADVANTAGES: - All professionals equal team members⇒ In case management, all healthcare professionals doctors, nurses, therapists, and specialists work as equal partners. This collaborative approach ensures that every team member's expertise is utilized and valued, leading to comprehensive care. It removes hierarchy, fostering a more collaborative environment. - Members take ownership of patient outcomes⇒ When team members share responsibility for the outcomes, they are more likely to be invested in the patient’s well-being. Each professional feels accountable for contributing to the patient's overall success, ensuring better follow-through on care plans and interventions. - Collaborative and integrated care approach⇒ Case management encourages an integrated approach to patient care, where all professionals collaborate, share information, and make coordinated decisions. This minimizes gaps in care, making sure no aspect of the patient’s treatment is neglected. - Improves communication between healthcare providers⇒ Case management enhances communication among the various professionals involved. This means that everyone is on the same page regarding the patient’s progress, needs, and next steps. Effective communication reduces misunderstandings and errors, ensuring a smoother care process. DISADVANTAGES: - Requires a qualified nurse case manager⇒ One of the main challenges of case management is the need for a highly skilled and experienced nurse to serve as the case manager. This individual is responsible for coordinating care, which requires not only clinical expertise but also excellent organizational and leadership skills. Finding and retaining such qualified professionals can be difficult. - Necessitates strong team collaboration⇒ Successful case management depends on effective teamwork, which can be challenging to achieve. Team members need to trust and respect one another, and without strong collaboration, care can become fragmented or inconsistent. - Needs a robust quality management system⇒ To ensure consistent, high-quality care, case management systems need to have strong quality management frameworks. These systems track patient outcomes, identify areas for improvement, and ensure that best practices are followed. Establishing and maintaining these systems can be resource-intensive. - Established critical pathways are essential⇒ Critical pathways (standardized, evidence-based care plans) must be in place for case management to work effectively. These pathways provide the guidelines that ensure patients receive the right care at the right time. However, developing and updating these pathways can be time-consuming and requires significant coordination among healthcare providers.  DIAGRAM: 1. Screening: → The initial step where patients or cases are identified based on specific criteria. Screening assesses if the patient is suitable for case management based on risk factors or needs. 2. Assessing: → This stage involves a detailed evaluation of the patient's needs, risks, and resources. It's where the case manager gathers information about the patient’s health status and other factors affecting care. 3. Planning: →After the assessment, a care plan is developed. This plan outlines the interventions, treatments, and services required to address the patient's needs effectively. 4. Implementing: →The care plan is put into action. This includes providing or coordinating the services and interventions as outlined in the plan. The case manager ensures that all steps are followed and resources are utilized. 5. Following-Up (Ongoing): → Case managers continuously monitor the patient's progress. Ongoing follow-ups help ensure that the interventions are working and allow adjustments to the care plan if needed. 6. Transitioning: → When the patient’s condition improves or changes, they may need to transition to another type of care or discharge from case management. This involves communicating the transition plan and making sure it is seamless. 7. Evaluating: → This final step involves assessing the effectiveness of the care provided. It looks at outcomes to ensure that the patient’s needs were met and considers what worked well and what could be improved.  3. INNOVATIVE/ CONTEMPORARY METHOD Expands the role of nurses beyond direct caregivers. Increased demand for more individualized and convenient care pathways is resulting in a shift away from the more traditional provider-driven healthcare models COMMON THEMES FOUND AMONG NEWER CARE DELIVERY MODELS 1. Elevating the role of nurses and transitioning from caregivers to “care integrators” 2. Taking a team approach to interdisciplinary care 3. Bridging the continuum of care outside of the primary care facility 4. Defining the home as a setting of care 5. Targeting high users of health care, especially older adults 6. Sharpening focus on the patient, including an active engagement of the patient and his or her family in care planning and delivery, and a greater responsiveness to the patient's wants and needs. 7. Leveraging technology 8. Improving satisfaction, quality and cost. A. Nurse Navigators - Help patients and families navigate the complex healthcare system by providing information and support. - Act as guide, resource, advocate, educator, and liaison for newly diagnosed cancer patients and their family. - Consistent caregiver through the cancer journey, coordinating appointments and schedules while keeping the patient and family actively involved in their plan of care. - Commonly occurs in targeted clinical settings such as oncology ,whereby a breast cancer nurse navigator might work with a woman from the time she is first diagnosed and then follow her throughout the course on her illness. Roles in Oncology: - Serves as a clinician, care coordinator, educator and counsellor for patients and families. - Help patients and their families understand the diagnosis and treatment plan. - Improves patient outcomes through education, support and monitoring. - Coordinates care with other health care providers such as radiologists, pharmacists,dietitians, social workers, case managers and counsellors. - Help the patient and family connect with community resources (working with social workers with expertise in this area) - Remain available and in contact with the patient and caregivers throughout the treatment process; the patient may call at any time day or night with questions about medication, symptoms, lifestyle changes, or other concerns. Skills for a Nurse Navigator 1. Cultural openness - A nurse navigator may be open to learning about different lifestyles and cultures by handling many patients. A patient's cultural experience might differ from the nurse navigator's, but they take time to listen and learn to help all patients feel most comfortable while engaging in treatments and healthcare procedures. 2. Commitment to patient confidentiality - nurse navigators might require more awareness because of their interactions with many people from different departments. 3. Respect for others - Having respect for other individuals might seem natural in healthcare, but the nurse navigator's position requires diligence in this field to show  understanding and patience. Nurse navigators can set a precedence of respect for others through achievable expectations and boundaries. 4. Strong communication - This position requires collaboration with other team members for effective healthcare service delivery. Being able to deliver reliable, responsive and open communication can help them meet their patient's needs. 5. Dedication to advocacy - A nurse navigator interacts with many patients, educating and guiding them through treatment procedures. Ensuring they accurately interpret medical information to patients and help them access quality treatment for their conditions. 6. Multitasking ability - Nurse navigators may perform various roles and responsibilities when providing care to their patients. Learning how to handle several tasks or cases at one time could be beneficial in this role. You may also benefit from enjoying a constant change in your daily routine, as each patient offers a unique set of challenges and rewards. B. Clinical Nurse Leader - Lead other members of the team. - An advanced generalist with a master’s degree in nursing, is expected to provide clinical leadership at the point of care in all health-care settings, implement outcomes-based practice and quality improvement strategies, engage in clinical practice, and create and manage microsystems of care that are responsive to the health-care needs of individuals and families (AACN, 2007). - CNLs have advanced knowledge and education in general practice as opposed to one primary discipline, like Clinical Nurse Specialist (Johnson & Johnson Services Inc.,2015). - Assumes accountability for health-care outcomes for a specific group of clients within a unit or setting through the assimilation and application of research-based information to design, implement, and evaluate client plans of care. - A provider and a manager at the point of care to individuals and cohorts and as such designs, implements, and evaluates client care by coordinating,delegating, and supervising the care provided by the health-care team ( AACN, 2007 ). - Plays a key role in collaborating with interdisciplinary teams. - Identifies risk analysis strategies and resources needed to ensure the safe delivery of care and then relies on patient-centered,evidence-based practice and performance data to make needed decisions (RWJ,2009). C. Patient and Family Centered Care - Represent a change in the paradigm of care and strongly influence how care must be delivered. - An innovative approach to the planning, delivery, and evaluation of health care grounded in mutually beneficial partnerships between patients, families, and healthcare providers ( Abraham & Moretz, 2012 ). - Planetree argues that patient-centered care is the “right thing to do”. It must be organized and should respect individual patient’s preferences, needs, and values. - An approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health-care providers, patients, and families, thus redefining the relationships in health care (IPFCC, 2010). - The Institute of Medicine identified patient-centered care as one of six points for health-care redesign and one way to provide care “that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions” - Core Concepts: 1. Patient care is organized first and foremost around the needs of patients 2. Patient and family perspectives are sought out and their choices are honored.  3. Health-care providers communicate openly and honestly with patients and families to empower them to be effective partners in their health-care decision making. 4. Patients, families, and health-care providers collaborate regarding facility design and the implementation of care. 5. The voice of the patient and family are represented at both the organizational and policy levels as well as in the health system’s strategic planning. > Pioneers of patient and family centered care: 1. Planetree - A mission-based nonprofit organization that provides partners with healthcare organizations around the world and across the care continuum to transform how care is delivered. - Plantree informs policy at a national level, aligns strategies at a system level, guides implementation of care delivery practices at an organizational level, and facilitates compassionate human interactions at a deeply personal level. 2. The IPFCC - a nonprofit organization offering health-care providers and institutionsinformation and core guiding concepts related to patient- and family-centered care. - Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families. It redefines the relationships in health care by placing an emphasis on collaborating with people of all ages, at all levels of care, and in all health care settings. - A key goal is to promote the health and well-being of individuals and families and to maintain their control. - Patient- and family-centered care is working "with" patients and families, rather than just doing “to” or “for” them. - This perspective is based on the recognition that patients and families are essential allies for quality and safety—not only in direct care interactions, but also in quality improvement, safety initiatives, education of health professionals, research, facility design, and policy development. - CORE CONCEPTS: - Respect and Dignity. Health care practitioners listen to and honor patient and family perspectives and choices. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care. - Information Sharing. Health care practitioners communicate and share complete and unbiased information with patients and families in ways that are affirming and useful. Patients and families receive timely, complete and accurate information in order to effectively participate in care and decision-making. - Participation. Patients and families are encouraged and supported in participating in care and decision-making at the level they choose. - Collaboration. Patients, families, health care practitioners, and health care leaders collaborate in policy and program development, implementation, and evaluation; in facility design; in professional education; and in research; as well as in the delivery of care. Reference: Whitehead, D., Weiss, S., & Tappen, R. (2010). Essentials of Nursing Leadership and Management (5th ed.). F.A. Davis Company.  GROUP 12 4A 4B 4C DEPONIO, Dresani Dijka D. SALIW-A, Analy CULAS, Moana ELIAS, Radjeny D. DELIM, Octryel Ann DOMALOS, Charlotte GAYAP, Algen DOMASING, Yolly DOMINGO, Kyreen GUINAYEN, Micah Jade MOCYAT, Geraldine SIENA, Almira LEGAL ASPECTS OF NURSING PRACTICE 1. ACCOUNTABILITY AND STANDARDS OF CARE FOR CLINICAL PRACTICE Nurses have authority, accountability, and responsibility to make decisions that result in safe, quality, and evidence-based nursing practice (American Nurses Association [ANA], 2015a, 2015b). At all levels, nurses must engage in responsible, accountable and competent nursing practice since it is also the expectation of society to nurses. Therefore, nurses are legally accountable to both their conduct and to those they assign care to. In addition, nurse leaders and managers must ensure that staff members maintain competence by having the knowledge, skills, and attitudes necessary to perform their professional responsibilities. Also it is important that they ensure that staff members practice legally within regulatory boundaries, considering that it is often entwined with the ethical and legal issues, in today’s health-care system. Therefore nurse leaders and managers must have a complete understanding of the: ○ minimum standards of clinical practice, ○ the requirements of licensure, ○ regulations that affect nursing practice and malpractice Accountability is “to be answerable to oneself and others for one’s own choices, decisions and actions as measured against a standard” (ANA, 2015a, p. 41) To become accountable, nurses at all levels must : ○ embrace an approach to nursing practice that includes application of ethical principles ○ respect the dignity, worth, and autonomy of regulatory agencies  ○ fulfillment of society’s need for conscientious and qualified nurses (ANA, 2010, 2015b) Standards of Care for Clinical Practice Standards of care are the level of quality considered adequate for nursing, which includes the minimum knowledge, skills and attitudes required to deliver an acceptable level of nursing care. In order to give registered nurses in the US the critical knowledge needed to inform clinical decision making and guide professional nursing practice, there are four fundamental resources that they should consult: 1. The ANA Code of Ethics for Nurses With Interpretive Statement (2015a), which was discussed in Chapter 4, details the ethical standards for nurses in all roles and in all settings. 2. Nursing’s Social Policy Statement: The Essence of the Profession (ANA, 2010) describes nursing’s commitment to society and provides a definition of nursing. 3. Nursing: Scope and Standards of Practice (ANA, 2015b) presents the standards of professional nursing practice and accompanying competencies. 4. The nurse practice act (NPA) of the state in which a nurse practices is discussed in greater detail in the next section, “Licensure and Regulation of Nursing Practice.” Nursing’s Social Policy Statement Nursing’s Social Policy Statement defines nursing, describes the role of professional nursing in society and health care, and provides an overview of the essence of nursing practice (ANA, 2010). Nursing is defined as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2010, p. 10). The profession of nursing has a contract with society that grants the profession authority and reflects nursing’s core values and strong code of ethics. This social contract identifies the profession’s active leadership role related to the following six social concerns (ANA, 2010, p. 4–5): 1. Organization, delivery, and financing of quality health care 2. Provision for the public’s health 3. Expansion of nursing and health-care knowledge and appropriate application of technology 4. Expansion of health-care resources and health policy 5. Definitive planning for health policy and regulation 6. Duties under extreme conditions The Nursing Social Policy Statement serves as a foundational tool that nurse leaders and managers can use to regularly reinforce with nursing staff: the ideas of competence and autonomy, the scope and standards of nursing practice, and the nursing process. This resource can provide a basis for creating the vision, mission, and philosophy of the unit in addition to helping with strategic planning. To provide a complete picture of the dynamic and complex nature of nursing practice, the “who, what, when, where, why, and how” of nursing practice must be detailed (ANA, 2015b). Nursing: Scope and Standards of Practice answers each of these questions and “describes a competent level of nursing practice and professional performance common to all registered nurses” (ANA, 2015b, p. 1). This document delineates the professional scope and standards of practice and responsibilities of all registered nurses in all settings and serves as a basis for the following (ANA, 2015b, pp. 49–50): Quality improvement systems Health-care reimbursement and financing methodologies Development and evaluation of nursing service delivery systems and organizational structures Certification activities Position descriptions and performance appraisals Agency policies, procedures, and protocols Educational offerings Regulatory systems Establishing the legal standard of care 2. LICENSURE AND REGULATION OF NURSING PRACTICE IN THE PHILIPPINES Licensure is the process by which boards of nursing grant permission to an individual to engage in nursing practice after determining that the applicant has the necessary competencies (National Council of State Boards of Nursing [NCSBN], 2020). Nursing licensure assures the public that those calling themselves nurses have met regulatory standards specific to the nursing profession. The basic requirements for a nursing license are graduating from an approved nursing program and successfully passing the Philippine Nurses Licensure Examination. ARTICLE IV: Examination and Registration according to “Philippine Nursing Act of 2002” 1. Licensure Examination. All applicants for license to practice nursing shall be required to pass a written examination, which shall be given by the Board in such places and dates as may be designated by the Commission: Provided, That it shall be in accordance with Republic Act No. 8981, otherwise known as the "PRC Modernization Act of 2000." 2. Qualifications for Admission (a) He/she is a citizen of the Philippines, or a citizen or subject of a country which permits Filipino nurses to practice within its territorial limits on the same basis as the subject or citizen of such country: Provided, That the requirements for the registration or licensing of nurses in said country are substantially the same as those prescribed in this Act. (b) He/she is of good moral character. (c) He/she is a holder of a Bachelor's Degree in Nursing from a college or university that complies with the standards of nursing education duly recognized by the proper government agency. 3. Ratings. In order to pass the examination, an examinee must obtain a general average of at least 75% with a rating of not below 60% in any subject. An examinee who obtains an average rating of 75% or higher but gets a rating below 60% in any subject must take the examination again but only in the subject or subjects where he/she is rated below sixty percent 60%. — In order to pass the succeeding examination, an examinee must obtain a rating of at least 75% in the subject or subjects repeated. 4. Oath. All successful candidates in the examination shall be required to take an oath of profession before the Board or any government official authorized to administer oaths prior to entering upon the nursing practice. 5. Issuance of Certificate of Registration/Professional License and Professional Identification Card and Fees for Examination and Registration. A certificate of registration/professional license as a nurse shall be issued to an applicant who passes the examination upon payment of the prescribed fees. Every certificate of registration/professional license shall show the full name of the registrant, the serial number, the signature of the Chairperson of the Commission and of the Members of the Board, and the official seal of the Commission. 6. Registration by Reciprocity. A certificate of registration/professional license may be issued without examination to nurses registered under the laws of a foreign state or country. 7. Practice Through Special/Temporary Permit. - A special/temporary permit may be issued by the Board to the following persons subject to the approval of the Commission and upon payment of the prescribed fees. However, That the special/temporary permit shall be effective only for the duration of the project, medical mission or employment contract. 8. Revocation and suspension of Certificate of Registration/Professional License and Cancellation of Special/Temporary Permit. The Board shall have the power to revoke or suspend the certificate of registration/professional license or cancel the special/temporary permit of a nurse upon any of the following grounds: (a) For any of the causes mentioned in the preceding section. (b) For unprofessional and unethical conduct. (c) For gross incompetence or serious ignorance. (d) For malpractice or negligence in the practice of nursing. (e) For the use of fraud, deceit, or false statements in obtaining a certificate of registration/professional license or a temporary/special permit. (f) For violation of this Act, the rules and regulations, Code of Ethics for nurses and technical standards for nursing practice, policies of the Board and the Commission, or the conditions and limitations for the issuance of the temporarily/special permit. (g) For practicing his/her profession during his/her suspension from such practice Provided, however, That the suspension of the certificate of registration/professional license shall be for a period not to exceed four (4) years. 9. Re-issuance of Revoked Certificates. When the cause for revocation has disappeared or has been cured and corrected, upon proper application therefor the Board may issue another copy of the certificate of registration/professional license. 10. Replacement of Lost Certificates. A new certificate of registration/professional license to replace the certificate that has been lost, destroyed or mutilated may be issued, subject to the rules of the Board. REGULATION. The nursing profession ensures that members act in the public’s best interest when providing nursing care through professional regulation, self-regulation, and legal regulation (ANA, 2010). Professional regulation consists of the oversight, monitoring, and controlling of members based on principles, guidelines, and rules deemed standard in the profession. Self-regulation is personal accountability for one’s professional nursing practice based on those same principles, guidelines, and rules; nurses regulate their own practice by maintaining current knowledge, skills, and attitudes through academic and continuing education. Legal regulation consists of oversight and monitoring based on applicable statutes and regulations such as licensure, nurse practice acts, civil law, and criminal law (ANA, 2010). The Philippine Board of Nursing (BON) The Philippine Board of Nursing is an administrative body under the Professional Regulation Commission that regulates the practice of nursing in the Philippines. 1. To provide regulatory standards in the practice of Nursing by implementing the Nurse Practice Act and by lobbying to Congress any proposed amendment to any laws with direct relationship to the practice of nursing. 2. To ensure public safety by administering the Philippine Nursing Licensure Exam (PNLE) to graduates of nursing schools prior to practice of Registered Nursing in the Philippines. 3. To maintain high standards of nursing education by auditing the performance of Philippine Nursing Schools. Philippine Nurses Association (PNA) The Philippine Nurses Association (PNA) is an accredited professional organization of registered nurses with their mission in promoting global competence, welfare, and positive and professional image of the Filipino nurse. Formerly known as Filipino Nurses Association (FNA) founded on September 1922 by Anastacia Giron Tupas. References: The Lawphil Project Arellano Law Foundation. (n.d.). Republic Act no. 9173. Retrieved October 3, 2024 from https://lawphil.net/statutes/repacts/ra2002/ra_9173_2002.html Philippine Nurses Association, Inc. (n.d.). Mission. Retrieved October 3, 2024 from https://pna-ph.org/the-company/house-of-deligates/tasks-and-responsibilities 3. FEDERAL AND/ OR STATE LEGISLATION Federal and state laws affect nursing practice by setting minimum standards of care for all agencies receiving federal funding. Nurses must become familiar with federal and/ or state legislation such as: a. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY (HIPAA) This was enacted in 1996 to: o To improve portability and continuity of health insurance coverage o Combat waste, fraud and abuse in health insurance and healthcare- delivery o Promote the use of medical savings accounts o Improve access to long- term care coverage and services o Simplify the administration of health insurance o Protect individuals from wrongful disclosure of identifiable health information HIPAA Privacy, Security and Breach Notification Rules protect the privacy of health information and provide individuals with rights to their health information. The Privacy Rule protects all identifiable health information or protected health information (PHI). This includes; o Information that relates to an individual's past, present, or future physical or mental health or condition o The provision of health care to the individual o The past, present, or future payment for the provision of healthcare to the individual Examples of PHI: Name, Social Security Number (SSS), Birthdate, Gender, Insurance Company Name and medical diagnosis HIPAA violation occurs when PHI is inappropriately used or is disclosed to a person not involved in the patient’s care, to a person who does not require the information to provide care, or in a situation in which disclosure is not in the patient's best interests (McGowan, 2012), which can result in substantial fines and prison sentences. Nurse leaders and managers must ensure that patient information remains PRIVATE and CONFIDENTIAL. b. PATIENT SELF- DETERMINATION ACT Congress passed in 1990 to ensure that healthcare organizations inform patients about their rights and institutional policies to accept or refuse treatment and to prepare advance directives (Beauchamp & Childress, 2019).  The basic premise of PSDA is to promote patients as active participants in healthcare decisions, thus increasing patient autonomy. PSDA requires hospitals and other healthcare agencies serving Medicare and Medicaid patients to develop and maintain written policies and procedures and to provide written information to adults receiving healthcare. Materials must describe the following: ✔ The individuals right under the law to make decisions about medical care, including the right to accept or refuse medical and surgical treatment. ✔ The individuals right under state law to dictate advance directives such as living wills or durable power of attorney for healthcare. ✔ The policies and procedures that the institution has developed to honor their rights. Institutions must specify how the advance directives are to be identified, recorded, and retrieved when needed. c. SAFE MEDICAL DEVICES ACT Enacted in 1990 and amended in 1992 to require healthcare agencies to report to the Food and Drug Administration (FDA) serious injuries, illness, or death resulting from the use of a medical device (SMDA,1990). When serious injury, illness, or death occurs, the SMDA requires healthcare agencies to report to the FDA within 10 days of the event the following information: name, serial number and model of the device; name and address of the manufacturer; and a brief description of the event. Nurses’ responsibility related to an incident involving a medical device covered under the SMDA includes the following (Brent,2001): ✔ Discontinue the use of the device immediately. ✔ Follow your agency’s policies related to equipment use. ✔ Document the incident accurately in the medical record, on an incident report, and on any agency- specific forms. ✔ Record the indentation number of the device in the medical record and other forms on a regular basis. Nurse leaders and managers are responsible for making certain that policies and procedures related to EQUIPMENT USE ARE IN PLACE and if equipment malfunction, nurse leaders and managers must facilitate processes to sequester the equipment to ENSURE PATIENT SAFETY. d. GOOD SAMARITAN LAWS To encourage healthcare professionals to render care in emergencies. Protect anyone who renders care during an emergency or disaster or at the scene of an accident as long as care is provided at the scene of the emergency, care is not grossly negligent, appropriate standards of care are used, and care is rendered without pay (Aiken, 2004; Guido, 2014) e. DISCLOSURE STATUTES Federal and state laws require disclosure of health- related information to appropriate government agencies to protect the public (Guido, 2014). Nurses as well as other healthcare professionals must report suspected child neglect and suspected child abuse to the state- designated officials. Some communicable diseases and sexually transmitted diseases must be reported to local or state public health officials.  f. EMPLOYMENT LAWS Federal and state governments are responsible to enact laws that protect employees from unfair treatment, discrimination and unsafe work conditions. 4. CLASSIFICATIONS OF LAW THAT RELATE TO NURSING PRACTICE Major Classifications (3Cs): Contract law, Criminal law, and Civil law. A. Contract Law Voluntary agreement between or among two or more competent people Creates an obligation for a person to do or not to do something Creates enforceable rights or legal duties B. Criminal Law Conduct that is harmful to society as a whole as well as to an individual victim. Crimes are classified as either a misdemeanor or a felony. Examples of misdemeanors: A nurse failing to report suspected child abuse or dependent adult abuse An individual using the title “nurse” or “registered nurse” without being duly licensed or certified. Examples of felonies: Some HIPAA violations and diversion of controlled substances from a health-care facility. Some violations of the state NPA can be charged as a felony C. Civil Law Rights and duties of private citizens; enforced through the courts as damages or monetary compensation. Tort law:  Foundation and the most common type of law that affects health-care professionals (Guido, 2014). A civil wrong committed against another person or a person’s property and includes personal injury inflicted on another through actions of commission or omission. Allows the injured person to seek monetary compensation for injuries at the expense of the wrongdoer (Brent, 2001). The three types of torts are as follows: 1. Intentional torts: Willful acts that are intentional and cause injury. A direct violation of a person’s legal rights and includes assault, battery, false imprisonment, and fraud. 2. Quasi-intentional torts: Willful acts that cause injury but are unintentional torts. Involves communication issues that result in defamation of character, violation of personal privacy, or breach of confidentiality (Aiken, 2004). 3. Unintentional torts: Careless acts or accidents that cause injury. Examples: Negligence and malpractice 5. NEGLIGENCE AND MALPRACTICE 3 types of Torts and How they Relate to Nursing Practice Intentional Torts 1. Assault ➔ Intentionally threatening a patient with physical harm 2. Battery ➔ Physically harming a patient 3. False Imprisonment ➔ Intentional confinement of a patient 4. Fraud ➔ Intentional misrepresentation that results in an illegal benefit to self or others Quasi-Intentional Torts 1. Defamation of Character ➔ Intentional written defamation (libel) or oral defamation (slander) of a patient 2. Violation of privacy ➔ Intentional intrusion into a patient’s privacy 3. Breach of Confidentiality ➔ Intentional sharing of a patient’s private health-care information they have shared with you Unintentional Torts 1. Negligence ➔ Failing to perform an action that a reasonably prudent nurse would do in a similar situation  2. Malpractice (Professional negligence) ➔ Unintentional injury to a patient as the result of a breach of duty Nurse leaders and managers can be considered negligent when they do not fulfill specific responsibilities such as the following (Guido, 2014): Failure to orient, educate, and evaluate Inappropriate assigning of staff and failure to supervise Unsafe staffing Negligent retention practices Failure to warn Elements of Malpractice 1. Duty Owed the Patient ➔ nurse–patient relationship that involves providing care and following an acceptable standard of care 2. Breach of duty ➔ results when care deviates from the standard 3. Foreseeability of harm ➔ The nurse must have reasonable access to information weather the possibility of harm exists 4. Causation ➔ the failure to meet the standard of care by action or lack of action caused harm or injury to the patient. 5. Injury or Harm ➔ actual harm that results from the breach of duty 6 areas of negligence that most frequently resulted in professional negligence were as follows: 1. Failure to assess and monitor 2. Failure to follow standards of care 3. Failure to communicate 4. Failure to document 5. Failure to act as a patient advocate 6. Failure to use equipment in a responsible manner 6. ADVANCE DIRECTIVES - a document that provides information about a person's desires should they become unable to make health-care decisions (coma patients) - remember: respect moral and legal rights of patients regarding self-determination - Nurses can be held liable for violating a patient’s advance directive and could be charged with BATTERY and MALPRACTICE - 18 years old or older can prepare an advance directive - Can be short and simple  - Can be reviewed by your doctor or lawyer Nursing Responsibilities Related to Advance Directives - Initiating discussion with a patient about advance directives - Providing a patient with written information about advance directives - Communicating the presence of an advance directive to all members of the health-care team - Ensuring that advance directives are current and accurately reflect the patient's wishes 3 Types of Advance Directives 1. Living Will - legal document that details a person's wishes regarding health-care treatments and procedures in the event that the person becomes incapacitated and is facing end of life - does not let other person to make decisions for you - Examples: Do not transfer to ICU; Comfort measures only 2. Durable Power of Attorney for Health Care - legal document that identifies a health-care surrogate - Surrogate: should have a clear understanding of the person's wishes regarding health care and be willing to respect those wishes even if they do not agree 3. Do Not Resuscitate (DNR) - life-sustaining measures (breathing machine, CPR) should be withheld in the event of impending death - As part of an AD, a DNR order is decided by the patient while competent or by his or her next-of-kin in the event of incompetence. - As patient advocates, nurses play an active role in initiating discussions about DNR orders with patients, families, and health-care team * Can a patient change their advance directive? - YES…As long as the patient is considered of sound mind, meaning able to think rationally and communicate clearly. - The changes should be made, signed, and possibly, notarized 7. CONFIDENTIALITY AND INFORMATION SECURITY Every patient has an ethical and legal right to privacy and confidentiality. Nurses are bound by their code of ethics to respect patients’ privacy and confidentiality, which includes ensuring patient information is secure at all times. Privacy  - refers to a person’s right to have control over access to their personal information. Privacy is not just an ethical principle but also a legal right and is protected by HIPAA. Patients confide in nurses and trust them with personal information. Nurses, in turn, must respect patients’ privacy and discuss patient information only with other health-care professionals and only on a need-to-know basis. - Nurse leaders and managers promote patient privacy when they create an environment that allows for physical and auditory privacy for discussion of patient information and establish policies and procedures that protect patient privacy (ANA, 2015a). Nurse leaders and managers show respect for employee privacy by keeping an employee’s religious beliefs and lifestyle choices private. Confidentiality Patients have little or no choice to share private information with nurses and other members of the health-care team. - Confidentiality means preventing disclosure of private information shared between a patient and the health-care team. Once a patient shares personal information, the nurse can use that information only as authorized by the patient. - Nurses are required to maintain confidentiality of all patient information. - Nurses at all levels have a duty to maintain confidentiality of all patient information, both personal and clinical, in the work setting and off duty in all venues, including social media or any other means of communication (ANA, 2015a, p. 9). - Nurse leaders and managers provide employees confidentiality by securing their personal information such as Social Security numbers and medical information. Only staff members who have a legitimate need within the performance of their job duties should have access to employee personal information. - The HIPAA, discussed earlier in this chapter, requires that nurses protect all verbal and written communication about patients, including medical records, electronic records, and verbal exchange of patient information such as patient teaching and change-of-shift report. The HIPAA requires health-care agencies to monitor staff adherence to related policies and procedures, computer privacy, and data security. Nurses must be aware of institutional policies and procedures related to patient privacy and confidentiality. A new area of concern internationally is the use of social media and other electronic communication. Although social networks such as Facebook, Twitter, Snapchat, Instagram, YouTube, and LinkedIn offer opportunities for knowledge exchange and dissemination among local, national, and global communities, they also pose substantial risks. All nurses have an obligation to understand the nature, benefits, and consequences of participating in social networking (ANA, 2011). Misusing social media can have severe consequences, such as disciplinary action by state boards of nursing that range from cautionary letters to licensure suspension. Violation of federal and state laws can result in civil or criminal penalties, including fines and imprisonment (Spector & Kappel, 2012). Nurses can also face liability for defamation, invasion of privacy, and harassment, depending on the type of postings and social media (NCSBN, 2011b, 2018b). Nurse leaders and managers are obligated to enforce organizational policies and procedures related to social media and networking and to address any breach of confidentiality and privacy immediately. As long as nurses remain aware of their professional obligations, using social networking will not be an issue. 8. INFORMED CONSENT is a legal process by which a patient or legal representative voluntarily gives permission for a treatment or procedure. There are two required components to informed consent: “The patient must be fully informed and there must be voluntary consent.” mandates that the patient must be given information in terms they understand, alternatives to the planned procedure, and the related risks and benefits of all options. This information allows the patient to make an informed decision. also represents the ethical principle of autonomy and reflects the patient’s autonomous decision to accept or refuse health care. Nurses must: obtain informed consent from their patients for all procedures, treatments, and interventions they perform. This type of informed consent is not necessarily a written document but must be a verbal consent or an implied consent based on the patient’s actions. This requires the nurse to continually communicate with patients about all procedures (e.g., injections, dressing changes, medication administration, etc.) and obtain their permission. In addition, nurses must also respect the patient’s right to refuse any procedures, treatments, and interventions. Accountability for obtaining informed consent for medical procedures lies with the healthcare provider. However, some institutions allow nurses to obtain the signature on the informed consent form for medical procedures being performed by another provider. In that case, the nurse’s role in obtaining informed consent includes the following (Guido, 2014): Verifying that the health-care provider gave the patient the necessary information to make an “informed” consent Ensuring that the patient understands the information and procedure or treatment Validating that the patient is competent to give consent Witnessing that the patient signs the consent form Notifying the health-care provider if the patient does not understand the procedure or treatment Documenting the informed consent process. The consent is considered valid until withdrawn by the patient (verbal or written) or until the patient’s condition changes significantly. > In an emergency, the physician can invoke implied consent, in which the physician states in the progress notes of the medical record that the patient is unable to sign but that treatment is immediately needed and is in the patient's best interest. Usually, this type of implied consent must be validated by another physician. > Nurses frequently seek express consent from patients by witnessing patients sign a standard consent form. In express consent, the role of the nurse is to be sure that the patient has received informed consent and to seek remedy if he or she has not.  NCM 119: NURSING LEADERSHIP AND MANAGEMENT WHAT IS A KARDEX? Kardex is a documentation system that enables nurses to write, organise , and easily reference key patient information that shapes their nursing care plan. It gives a brief overview of each patient and is updated every shift. It is like having a cheat sheet for nurses to reference that is separate from the patient chart. It is usually kept in a central location, such as the nursing station, for quick access. Nurses use kardex to communicate important information about their patients. It is a record of medical and nursing orders of each patient in the ward MAINTENANCE OF NURSING KARDEX A Kardex will be maintained for all patients cared for in the ward. It will be checked and revised as needed, before giving care and daily after doctors rounds Only standard abbreviations will be used in writing orders on the Kardex. Do not abbreviate the name of the medications. Pencils are used in recording details. It is used during endorsement. Method of filling Kardex I. Identification Data: Use capital letters to record. Name - copy accurately and completely from the admission record Diagnosis - Record provisional diagnosis. Any changes in the working diagnosis Surgical procedure done with date II. Medication: a) Write date, form and the name of the medication, frequency of administration in 24 hours, route of administration if other than oral and specific instructions concerning administration in column marked "medication". b) In a column marked "Dosage" Write the amount to be administered at the time of each administration. c) In the column marked "time" write the hours of administration.  d) Stat, P.R.N. and S.O.S. medication orders should not be recorded in the Kardex card but the medicine card should be prepared and should be inserted in the Kardex. e) Alternate day, weekly and bi weekly medications with the pencil the due dates for three consecutive dosage III. Treatments: a) In the column marked "treatment" write: date and name of the treatment, Example I/V, irrigation, diet, therapy, external applications, baking, frequency in 24 hours. And if applicable site, duration, temperature or strength of solutions and instructions. IV. Nursing Care Plan a) Write order relating to needed nursing care plan of the patient such as o Hygienic care: ▪ Special Mouth care ▪ Shampoo o Posture and position ▪ Frequency in 24Hrs o Activity, rest and exercise. o Control of pain o Needs for health teaching or nursing care following discharge. o Needs for support in relation to emotions or mental attitudes. o Food or Fluid - Intake ▪ Type ▪ Amount ▪ Frequency ▪ Elimination o Use of comfort devices and safety measures o Recreation and diversion. ▪ Plan to meet the spiritual needs ▪ In the "time" column indicate the specific hours for carrying out nursing care if applicable. ▪ Bath Record if bed bath or shower, frequency and if not daily the specific days of week the bath is to be given. o T.P.R. - Record the method of taking if other than oral. o Diet - Record the type of diet ordered, supplementary feedings, if ordered. ▪ Limitation of food or fluid if applicable. o Health education of; o Disease  o General o Family Planning o Prevention of disease Kardex Management Completeness and Integrity: The Kardex must be updated regularly to reflect any changes in the patient’s care plan. Nurses are responsible for ensuring that the Kardex contains accurate and current information to maintain its integrity. In electronic versions, updates can be automatically populated from the Electronic Health Record (EHR). Accessibility and Security: Kardex must be easily accessible to nurses during shifts. This is facilitated by electronic systems, which allow information to be accessed quickly on computers. However, strict security protocols are required to protect sensitive patient data, such as implementing user access controls and encryption. Safety: Regular audits and compliance checks help ensure that Kardex is being used properly. For electronic Kardex systems, strong cybersecurity measures must be in place to prevent data breaches or unauthorised access. PATIENT’S CHART/ MEDICAL RECORDS It promotes clear communication and facilitates effective decision-making. A well- organised medical chart typically follows a standardised format to ensure consistency and accuracy. Parts of a Patient’s Chart: 1. Demographic Information: The patient's chart should begin with their demographic details to ensure easy identification of the patient, such as name, date of birth, contact information, and insurance information. 2. Chief Complaint: This section helps healthcare providers quickly understand the patient's primary concern and immediate needs. 3. Medical History: Patient background is crucial as it helps healthcare professionals understand the patient’s overall health status by providing insights into their past  illnesses, surgeries, allergies, and chronic conditions. 4. Medication List: An up-to-date record of the medications a patient is currently taking, including dosage and frequency. This information helps healthcare providers avoid potential drug interactions and prescribe appropriate treatments. 5. Vital Signs: Tracking a patient's vital signs, such as blood pressure, heart rate, temperature, and respiratory rate, is a crucial part of a medical record when it comes to assessing their overall health status and physiological condition. 6. Laboratory Results: Documenting test results, such as blood tests and pathology findings, is essential for monitoring a patient's health and tracking their progress over time. These results aid in diagnosing and managing medical conditions. 7. Progress Notes: This section details each patient encounter, including subjective information, objective findings, assessments, and treatment plans. These notes serve as a chronological record of a patient's care and enable healthcare providers to track their progress. 8. Consultation Reports: If a patient receives specialized care from other healthcare professionals or specialists, their consultation reports should be included in the medical chart. These reports provide specialized insights and recommendations for the patient's ongoing care. 9. Imaging and Diagnostic Reports: Medical charts should contain a section dedicated to storing imaging reports, such as X-rays, MRIs, or CT scans, as well as other diagnostic reports. These documents provide visual evidence and aid in diagnosing and treating medical conditions. 10. Discharge Summary: When a patient is discharged from a healthcare facility, a comprehensive summary should be prepared. This summary includes details of the patient's hospital stay, diagnoses, treatments, medications, and any necessary follow- up instructions. It helps ensure a smooth transition of care between healthcare settings. Importance of a Patient’s Chart: 1. Continuity of Care: A patient's chart ensures the continuity of care between different healthcare providers. When multiple healthcare professionals are involved in a patient's treatment, the chart provides a centralised repository of information, enabling seamless communication and coordination. 2. Legal and Ethical Considerations: Thorough documentation in a patient's chart protects healthcare providers legally and ethically. It serves as a legal record of the care provided and the decisions made. In case of any legal disputes or medical malpractice claims, a well-documented chart can serve as crucial evidence. 3. Communication and Collaboration: A patient's chart serves as a means of communication among healthcare professionals involved in the patient's care. Accurate and up-to-date documentation ensures that important information is shared effectively, preventing misunderstandings and promoting collaboration. 4. Treatment Planning and Decision-making: A comprehensive patient chart provides healthcare providers with a holistic view of the patient's health history, current condition, and previous treatments. This information is vital for developing appropriate treatment plans and making informed decisions about the patient's care.  5. Quality Assurance and Research: Medical charts play a significant role in quality assurance and research endeavours. Aggregated and anonymized patient data from medical charts can be analysed to identify trends, improve healthcare practices, and contribute to medical research. 6. Billing and Reimbursement: Accurate documentation in a patient's chart supports appropriate billing and reimbursement for healthcare services provided. It ensures that the services rendered are properly coded and documented, facilitating timely and accurate claims processing. MANAGEMENT OF RELEASING PATIENT INFORMATION/RECORD All medical records information is deemed to be strictly confidential and cannot be disclosed to any unauthorised personnel under any circumstances without proper authorization. Certain exceptions which require hospitals to release the medical information of a patient are as follows: 1. The medical record needs to be shared with a different physician or hospital in order to provide better medical treatment of the patient. 2. If a court order for its release is obtained in medicolegal cases such as accidents, medical negligence, etc. 3. If a patient asks for copies of the medical records to seek a second opinion from another physician. 4. A health care power of attorney of the patient has the right to access the medical records as long as the patient has signed a release of records but the extent of access will be limited to those information which will be required to make an informed decision. 5. If a health insurance company asks for medical records for claim settlement. 6. If the patient is a minor, the parents have the right to seek copies of the child's medical records. MANAGEMENT OF RECONSTRUCTING MEDICAL RECORDS: A disaster recovery plan is crucial for every healthcare facility in the event of a failure of the medical records department to preserve the records of the patients. Simple steps that can be taken to safeguard the medical records in an unforeseen circumstance are 4’s: 1. Salvage: Save medical records from being damaged or destroyed. 2. Search: Conduct exhaustive search to locate the missing records. 3. Start reconstruction: If a document is permanently lost, attempt to reconstruct such as reprint or retranscribe. 4. Scribe: If all above fails, the facility should make a documentation of the date on which the disaster took place, number of patient medical records lost, natural or manmade disaster that caused the loss, and possible efforts made to recover the records. DESTRUCTION OF MEDICAL RECORDS 1. Shredding - destruction method of paper-based medical records 2. Incinerating - destruction method of electronic media (magnetic tape, microfilm, floppy disk, CD, or DVD) A simple medical record destruction form would contain the following: 1. Name of the authorizer 2. Period for which the records are destroyed or purged 3. Medical record number 4. Date of destruction 5. Method of destruction 6. Name of the destroyer and witness if any REMEMBER: As the saying goes, “ IF IT WAS NOT CHARTED, IT WAS NOT OBSERVED OR DONE” References: Healthie Inc. (2024, May 22). 10 different parts of a patient medical chart. Healthie Inc. https://www.gethealthie.com/blog/10-different-parts-of-a-patient-medical- chart#:~:text=A%20patient's%20medical%20chart%20is%20a%20crucial%20tool%2 0in%20healthcare Medical Records Management. (n.d.). We School Welingkar Education. Retrieved from http://elearning.nokomis.in/uploaddocuments/Revenue%20Cycle%20Management%2 0in%20Healthcare/Chapter%201- %20Medical%20Records%20Management/PPT/1.Medical%20Records%20Managem ent.pdf https://www.slideshare.net/LakshmiChowdary28/nursing-kardex-recordingpptpptx? fbclid=IwY2xjawFp50RleHRuA2FlbQIxMAABHRfwcGGH9LjUNsvhO2Vhu8qPfPn-8BFzLws- lqlX38p3xQ43XXdbz6u3-Q_aem_lO_N_MSpPYSZchsrwC3G7A  https://cjni.net/journal/?p=6338 https://www.intelycare.com/facilities/resources/what-is-kardex-nursing-technology-overview-and- faq/ https://cjni.net/journal/?p=8579 Members: Ore, Zennia Ericel Montero, Khate Emerlyn Cruz, Shekinah Arrielle Nacatab, Alvin Greg Balbin, Rhona Borja, Verlene Jessamine Mano, Maricar Umayat, Althea Abidal, Ira Comaad, Carreonellae Crosby, Arlyn Joyce Guimawa, Xynneth Acosta, Ivy B. Foster, China Joy L. Balang, Lorycel L. Gasalao, Romalyn Vina R. Cahilig, Jaira Guzman, Snow Sapphire D. Cayacay, Karen Rose W. Lupdag, Ruvi May C. Edeco, Zephanie M. Solonio, Bernadine M. Enaro, Kristine May D. Wance, Emyrita T. Record Management 1. Sentinel event Sentinel events are patient safety events (not primarily related to the natural course of the patient’s illness or underlying condition) that reach a patient and result in any of the following: o Death o Permanent harm o Severe temporary harm (critical, potentially life-threatening harm lasting for a limited time with no permanent residual but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition, or additional major surgery, procedure, or treatment to resolve the condition. Events are sentinel if they include: Suicide of any patient receiving care, treatment, and services in a staffed around-the- clock care setting or within 72 hours of discharge, including from the hospital’s emergency department (ED) Unanticipated death of a full-term infant Discharge of an infant to the wrong family Abduction of any patient receiving care, treatment, and services Any elopement (that is, unauthorized departure) of a patient from a staffed around-the- clock care setting (including the ED), leading to death, permanent harm, or severe temporary harm to the patient Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities (ABO, Rh, other blood groups) Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on site at the hospital Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure Unintended retention of a foreign object in a patient after an invasive procedure, including surgery Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter) Prolonged fluoroscopy with cumulative dose >1,500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care Any intrapartum (related to the birth process) maternal death Severe maternal morbidity (not primarily related to the natural course of the patient’s illness or underlying condition) when it reaches a patient and results in any of the following: Permanent harm or severe temporary harm Sentinel event data, 2014 to second quarter, 2017 by The Joint Commission Retention of foreign body Wrong-site surgery Fall  Suicide Delay in treatment Operative/postoperative complication Criminal event Medication error Perinatal death/injury Responses to a Sentinel Event: Stabilize the patient Disclose the event to the patient and family Provide support for the family and staff involved Notify the hospital leader Immediate investigation Comprehensive systematic review Root cause analysis (RCA) for identifying the causal and contributory factors Strong corrective actions to eliminate the root cause and prevent similar future events Establish a timeline for the implementation of corrective actions System improvement Root Cause Analysis (RCA) Is a systematic process used to identify the underlying causes of a sentinel event to prevent future occurrences. Here are the key components: Event Description: Detailed documentation of the sentinel event, including what happened, when, where, and who was involved. Timeline: Chronological sequence of events leading up to the sentinel event. Contributing Factors: Identification of factors that contributed to the event, such as human error, system failures, or environmental issues. Root Cause Identification: Determination of the fundamental cause(s) of the event through asking "Why?" repeatedly until the root cause is identified. Corrective Actions: Development of strategies and actions to address the root cause and prevent recurrence. Implementation Plan: Plan for implementing corrective actions, including assigning responsibilities and setting timelines. Follow-Up: Monitoring and evaluation of the effectiveness of corrective actions to ensure they are working as intended. Sentinel Event Policy: All healthcare organizations should have a response policy. Organizations that are either voluntarily reporting a sentinel event or responding to JC’s inquiry about a sentinel event submit their related RCA and action plan electronically to JC whenever such events occur. Goals of Joint Commission’s Policy (1996): Improve patient care and prevent future events. Analyze root causes (cultural, latent, and active failures) and develop actionable plans. Raise awareness and share learnings on sentinel events and mitigation strategies. Maintain public, staff, and hospital trust by prioritizing patient safety. Sentinel Event Database: Joint Commission collects identified sentinel event data. Data helps raise general awareness and promote error prevention strategies. Reporting a Sentinel Event: Reporting to the Joint Commission is voluntary. Benefits of Reporting: Increases awareness of potential sentinel events and prevention strategies. Provides consultation for systematic review, root cause analysis, and action plan development. Reinforces a hospital’s commitment to a culture of safety for public and staff trust. 2. Anecdotal Report Introduction: Type of anecdotal method of data collection in which informal reports of a particular behavior are recorded through observations. The concept stems from the general idea of an anecdote, which is a personal account of something that someone experienced or witnessed. Definition: A collection of notes about a particular behavior, individual, or group taken by an observer during an observation or a series of observations. May include a variety of observations, such as things that were spoken during a conversation, the occurrence or frequency of actions or behaviors, and an individual's ability to solve a particular problem. Purpose: To finish the multiplicity of evidence needed for good cumulative record. To understand individual's basic personality pattern and his reactions in different situation. It can be maintained in the areas of behavior that cannot be evaluated by other systematic methods. Useful in supplementing and validity observations made by other means. Record unusual events, such as accidents. Record how an individual is progressing in a specific area of development. It provides a means of communication between the members of the health care team and facilitates coordinated planning and continuity of care. It acts as a medium for data exchange between the health care team. Clear, complete, accurate and factual documentation provides a reliable, permanent record of patient care. Anecdotal records help in clinical service practices. Anecdotal records can be used by the counselor as a source of information for giving evidence. Characteristics: They should contain a factual description of what happened, when it happened, and under what circumstances the behavior occurred. Each anecdotal record should contain a record of a single incident. Records typical or unusual behaviors Result of direct observation Accurate and specific Guidelines: Keep a notebook handy to make brief notes to remind you of incidents you wish to include in the record. Also include the name, time and setting in your notes.  Write the record as soon as possible after the event. The longer you leave it to write your anecdotal record, the more subjective and vaguer the observation will become. Describe the actions and what was said. Include the responses of other people if they relate to the action. Describe the event in the sequence that it occurred. Record should be complete. They should be compiled and filed. Principles: What actually happened, with series of events? How did it occur? When did it happen (with day and time)? Where did it happen (the place of event)? Remedial measures taken and the effect of measures. Incidents that needs to be reported: Events that seriously threaten the patient or staff. Events that lead to injury or death of the patient or staff. Patient behavior that could result in potential risk to the patient or others. Frequent behavior is reportable behavior of the same incident be a patient that occurs more than once in a shift or workday. Advantages: Provision of insight into total behavioral incidents. Needs no special training. Use of formative feedback. Economical and easy to develop. Open ended and can catch unexpected events. Disadvantages: If carelessly recorded, the purpose will not be fulfilled. Only records events of interest to the person doing the observing. Incidents can be taken out of context. Time consuming. 3. Incident Report Definition: Incident report is a safety tool wherein this provides a record, written account of the chain of events leading up to and following unforeseen circumstances in a healthcare setting. These reports can be used to identify areas of safety improvement and to educate others about how to avoid similar events in the future. Filing Incident Report: Reports are typically completed by nurses or other licensed personnel. They should then be filed by the healthcare professional who witnessed the incident or by the first staff member who was notified about it. Patient incident reports should be completed no more than 24 to 48 hours after the incident occurred. Purpose: Patient incident reports communicate information to facility administrators. These reports help administrators with:  Risk management: knowing that an incident has occurred can push administrators to correct factors that contributed to the incident. This reduces the risk of similar incidents in the future. Quality control: medical facilities want to provide the best care and customer service possible. Reviewing incident reports reveals areas that could be improved. Training: using resolved patient incident reports to train new staff and prepare them for real situations that could occur in the facility. Similarly, current staff can review old to learn from their own or other’s mistakes and keep more incidents from occurring. Legal evidence: should a patient take legal action following their incident a thorough incident report is the most important part of any defense. Thus, all reports should be timely, complete, and accurate. Benefits: Preventive Measures: Analyzing past incidents helps predict and prevent future issues, improving care and safety. Disease Monitoring: Reports assist in tracking potential disease outbreaks, example is during COVID-19. Cost Reduction: Better reporting reduces legal and operational costs by avoiding medical errors. Enhanced Patient Safety: Incident reporting leads to fewer errors, higher safety standards, and better patient care, boosting the hospital's reputation. Types: 1. Clinical Incidents: is an unpleasant and unplanned event that causes or can cause physical harm to a patient. These incidents are harmful in nature; they can severely harm a person or damage the property. 2. Near Miss Incidents: is when there was potential harm to a patient and was almost harmed, but the station was corrected before it occurred. 3. No- Harm Incidents: means that something happened to a patient, but no discernible injury or illness resulted. Components: 1. General Information: Include the incident's date, time, and basic details for analysis. 2. Location: Specify exactly where the incident occurred, aiding investigation and prevention. 3. Incident Description: Be clear and objective; avoid vague or biased language. 4. Type of Incident: Categorize the incident, such as medication error, patient fall, or equipment damage, to clarify its nature and guide responses. 5. Injury Level: Document the severity and cause of any injuries, and note follow-up medical information if needed. 6. Witnesses: Names and contact information of any witnesses to the incident. 7. Actions Taken: Immediate actions taken in response to the incident (e.g., medical intervention, moving the patient to a safe area). 8. Follow-up Actions: Recommendations for further action or steps taken after the incident (e.g., monitoring the patient, investigating the cause). 9. Person Completing the Report: The name, position, and signature of the person who is completing the report. Do’s and Don’ts in completing an incident report: Do’s: Complete the report promptly: Fill out the report as soon as possible after the event, but only after ensuring the safety of the person affected and completing any immediate follow-up actions.  State objective facts: Record only the facts that you personally witnessed or know for certain. For example, write: “The patient was found on the floor next to the bed.” Avoid assumptions like “The patient fell out of bed,” as this is not verified. Provide a clear, detailed description: Describe what happened in a clear, concise manner, including all relevant details. Include relevant direct quotes: If witnesses or those involved provide statements, include them in quotation marks. For example, a family member might say, “He didn’t want to wear his non-skid slippers and slipped on the floor.” Don’ts: Avoid subjective information: Do not include assumptions, opinions, or personal suggestions about how to prevent similar incidents in the future. Do not reference the incident report in medical records: It is inappropriate to document in the patient’s health record that an incident report was filed. Avoid unclear abbreviations: Do not use abbreviations that may not be widely understood. References: Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management function in nursing: Theory and application. (9th ed). Lippincott Williams and Wilkins, Philadelphia. Patient Safety. (n.d.). Incident reporting in nursing. Patient Safety. https://www.patientsafety.com/en/blog/incident-reporting-in-nursing Patra, K. P., & De Jesus, O. (2023, March 29). Sentinel event. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK564388/ QUASR. (2021, December 1). Incident reporting in healthcare: A complete guide. QUASR. https://www.quasrapp.com/blog/incident-reporting-in-healthcare/ Saver, C. (n.d.). Incident reports: A safety tool. Nurses Service Organization (NSO). https://www.nso.com/Learning/Artifacts/Articles/Incident-reports-A-safety-tool Thukral, V. (2020). Nursing Records and Reports. Jamia Hamdard.  TEAMWORK AND COLLABORATION ABALOS, Ernest John GAPUZ, Crisyl ASIONG, Kyle GUINIAWAN, Janelle BAUSA, Edrie Lag-ey, Rochelle BERZABAL, Samuel LAGMAN, Rhyza CAWI, Christabel PERALTA, Airish Angel GALONZA, Ymari Ghyt TUAZON, Denzel Objectives 1. Be able to know the structure of the Hospital and Community Setting 2. Know how the collaboration in each setting functions as a team 3. The difference between Hospital and Community settings in terms of impact 4. Identify how to enhance team cohesion and collaboration in hospital or community setting Concepts of Team Collaboration in hospital setting and community setting I. Hospital Setting 1. Team Composition a. Physicians - Attending Physicians: Lead the medical care for patients, make diagnoses, and develop treatment plans. - Residents: Doctors in training who work under the supervision of attending physicians. - Specialists: Physicians with advanced training in specific areas (e.g., cardiologists, surgeons). b. Nurses - Registered Nurses (RNs): Provide direct patient care, administer medications, and coordinate care. - Licensed Practical Nurses (LPNs): Support RNs and assist with basic patient care tasks. - Nurse Practitioners (NPs): Advanced practice nurses who can diagnose and treat patients independently. c. Allied Health Professionals - Pharmacists: Manage medication therapies and counsel patients on drug interactions. - Physical Therapists: Help patients recover mobility and strength through rehabilitation exercises. - Occupational Therapists: Assist patients in regaining skil