Sean Whitfield NURS 3000 - Professional Nursing ALG 4 - Complete.pdf

NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation Legal and Ethical Guidelines, Documentation Name: Click or tap here to enter text. Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide...

NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation Legal and Ethical Guidelines, Documentation Name: Click or tap here to enter text. Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respond to any case studies and client scenarios. All of these activities will assist in your preparation for exams, help you plan and implement care in the clinical setting, and facilitate your development as a Christian nurse servant. You will submit your completed guide to the instructor at the end of the week. The completed learning guide will be worth a maximum of 10 points. If you have questions or are unsure about your answers you may email your instructor for clarification. Note: The Active Learning Guide provides a general outline of topics covered in this module; it is not all inclusive of all information needed for the exam. You are responsible for all content in readings and activities throughout the module. I. Legal Aspects of Nursing: Chapter 3 1. Functions of the law in nursing are: Give a framework for establishing which nursing actions in the care of clients are legal. It will differentiates the nurse’s responsibilities from those of other health professionals. It is used to help establish the boundaries of independent nursing action. It assists in maintaining a standard of nursing practice by making nurses accountable under the law. 2. Discuss the sources of law. The legal system in the United States has its origin in the English common law system. The Constitutional Law of the United States is the supreme law of the country. It establishes the general organization of the federal government, grants certain powers to the government, and places limits on what federal and state governments may do. Legislation, Statuatory Laws enacted by any legislative body are called statutory laws. When federal and state laws conflict, federal law supersedes. Likewise, state laws supersede local laws. The regulation of nursing is a function of state law. State legislatures pass statutes that define and regulate nursing, that is, nurse practice acts. These acts, however, must be consistent with constitutional and federal provisions. NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation Administrative Law, When a state legislature passes a statute, an administrative agency is given the authority to create rules and regulations to enforce the statutory laws. For example, state boards of nursing write rules and regulations to implement and enforce a nurse practice act, which was created through statutory law. Common Law, Laws evolving from court decisions are referred to as common law. In addition to interpreting and applying constitutional or statutory law, courts also are asked to resolve disputes between two parties. Common law is continually being adapted and expanded. 3. How can nurses keep legislators informed regarding what nurses need? Clinical Alert p. 40 It is important for nurses to keep their legislators informed about nursing because it is the legislature that passes laws that affect nursing practice. 4. What is the difference between public and private law? Public law refers to the body of law that deals with relationships between individuals and the government and governmental agencies. An important segment of public law is criminal law, which deals with actions against the safety and welfare of the public. Private law, or civil law, is the body of law that deals with relationships among private individuals. It can be categorized into a variety of legal specialties such as contract law and tort law. Contract law involves the enforcement of agreements among private individuals or the payment of compensation for failure to fulfill agreements. Tort law defines and enforces duties and rights among private individuals that are not based on contractual agreements. 5. Review Table 3.1 Selected Categories of Laws Affecting Nurses Why is it important for the nurse to be aware of law affecting the nurse/employer relationship? Nurses should be aware of what they are legally responsible for and the possible punishment they can become subject to if they breach a contract or do not fulfill an agreement. 6. Define Expert Witness: An expert witness has special training, experience, or skill in a relevant area and is allowed by the court to offer an opinion on some issue within his or her area of expertise. The nurse’s credentials and expertise help a judge or jury understand the appropriate standard of care. The nurse expert, thus, has the ability to analyze the facts or evidence and draw inferences. The literal usage of evidence to come to conclusion using critical thinking. NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation 7. Who enforces the Nurse Practice Act? The government agency (State Board of Nursing) issuing the RN license views the holding of that license to be a privilege, not a right. Each state has a mechanism by which licenses can be revoked for just cause (e.g., incompetent nursing practice, professional misconduct, or conviction of a crime such as using illegal drugs or selling drugs illegally). In each situation, a committee at a hearing reviews all the facts. Nurses are entitled to be represented by legal counsel at such a hearing. If a nurse’s license is revoked as a result of the hearing, either the nurse can appeal the decision to a court of law or, in some states, an agency is designated to review the decision before any court action is initiated. Why is it the most important document about which the nurse needs to be aware? Nurse practice acts, although similar, do differ from state to state. For example, they may differ in their scope of practice definition and in licensing and license renewal requirements. It is the nurse’s responsibility to know the nurse practice act of the state in which he or she practices nursing. 8. Discuss the differences between licensure and certification. Certification is the voluntary practice of validating that an individual nurse has met minimum standards of nursing competence in specialty areas such as maternal–child health, pediatrics, mental health, gerontology, and school nursing. A license is a legal permit that a government agency grants to individuals to engage in the practice of a profession and to use a particular title. Nursing licensure is mandatory in all states. For a profession or occupation to obtain the right to license its members, three criteria must generally be met: 1. There is a need to protect the public’s safety or welfare. 2. The occupation is clearly delineated as a separate, distinct area of work. 3. A proper authority has been established to assume the obligations of the licensing process, for example, in nursing, state boards of nursing. 9. Why is the accreditation of an educational institution important to the nurse? One of the functions of a state board of nursing is to ensure that schools preparing nurses maintain minimum standards of education. This is a legal requirement. Maintaining voluntary professional accreditation is a means of informing the public and prospective students that the nursing program has met certain criteria. 10.What is the purpose of nursing standards of care? The purpose of standards of care is to protect the public. Standards of care are the “skills and learning commonly possessed by members of a profession.” These standards are used to evaluate the quality of care nurses provide and, therefore, become legal guidelines for nursing practice. NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation 11.Define liability. Liability is the quality or state of being legally responsible for one’s obligations and actions and for making financial restitution for wrongful acts. A nurse, for example, has an obligation to practice and direct the practice of others under the nurse’s supervision so that harm or injury to the client is prevented and standards of care are maintained. 12.Why is the Enhanced Nurse Licensure Compact important to a registered nurse? The eNLC allows all RNs and LPNs to have one multistate license, with the ability to practice in both their home state and all other compact states. As of January 2019, 31 state legislatures have adopted eNLC. The goal is to have all 50 states in the compact. Thus, according to the state-based model, a nurse who electronically interacts with a client in another state to provide health information or intervention is practicing across state lines without a license in the other state. It provides an opportunity or escalation to mutually level the standards of care for nurses in multiple states to ensure torts and agreements are fulfilled and maintained between nurse and patient. Table 3.2- Legal Roles, Responsibilities, and Rights 13.What is the difference between a right and a responsibility? p. 46 A right is a privilege or fundamental power to which an individual is entitled unless it is revoked by law or given up voluntarily. A responsibility is the specific accountability or liability associated with the performance of duties of a particular role. 14.Define Informed Consent: Informed consent is an agreement by a client to accept a course of treatment or a procedure after being provided complete information, including the benefits and risks of treatment, alternatives to the treatment, and prognosis if not treated by a healthcare provider.  What are the three main elements? 1. The consent must be given voluntarily. 2. The consent must be given by a client or individual with the capacity and competence to understand. 3. The client or individual must be given enough information to be the ultimate decision maker.  Express Consent: Express consent may take the form of either an oral or a written agreement. Usually, the more invasive a procedure or the greater the NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation potential for risk to the client, the greater the need for written permission.  Implied Consent: Implied consent exists when the individual’s nonverbal behavior indicates agreement. For example, clients who position their bodies for an injection or cooperate with the taking of vital signs infer implied consent. Consent is also implied in a medical emergency when an individual cannot provide express consent because of physical condition.  Who can and cannot give informed consent? Can The competent adult client is expected to have the autonomy to make his or her own healthcare decisions. Along with parents and guardians of minors. Cannot Minors or adults with the mental capacity of a child. Confused, sedated, disoriented or unconscious persons. 15.What information is generally included in an informed consent document? Informed consent is an agreement by a client to accept a course of treatment or a procedure after being provided complete information, including the benefits and risks of treatment, alternatives to the treatment, and prognosis if not treated by a healthcare provider 16.What three things does the nurse’s signature on an informed consent confirm? The nurse’s signature reinforces or validates informed consent. The client gave consent voluntarily. The signature is authentic. The client appears competent to give consent. How can the nurse be a client advocate regarding informed consent? The nurse advocates for the client by verifying that the client received enough information to give consent. Therefore, it is important for the nurse to assess the client’s understanding and identify any misconceptions. The nurse can ask clients to restate in their own words what the individual who is going to perform the procedure explained to them. If the client has questions or if the nurse has doubts about the client’s understanding, the nurse must notify the healthcare provider. Again, the nurse is not responsible for explaining the medical or surgical procedure. In fact, the nurse could be liable for giving incorrect or incomplete information or interfering with the client–provider relationship. 17.Substance Use Disorder  Why do you think SUD is so high among nurses? NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation Nurses may be at an increased risk because of easy access to medications, the stressors of nursing, and lack of education on the addictive process and its signs and symptoms. Nurses administer medications for all purposes (e.g., to relieve pain, prevent infections, decrease anxiety and depression). The availability of drugs is an occupational hazard, especially if the administration of controlled substances in the healthcare agency is poorly managed. Increased client acuity, variable working hours, staffing shortages, fatigue, and isolation can cause stress. Substance use may be a way of coping with the stress.  What is a nurse’s (also nursing student) responsibility when working with an impaired colleague? it is important to remember that nurses have a professional and ethical responsibility to report a colleague’s unsafe practice or suspected drug use to their nurse manager or supervisor, and in some states, to the board of nursing. Reporting a nurse may save the nurse’s license and possibly his or her life. 18.What is an Advance Healthcare Directive? Advance healthcare directives include a variety of legal and lay documents that allow individuals to specify aspects of care they wish to receive should they become unable to make or communicate their preferences. The Patient Self-Determination Act implemented in 1991 requires all healthcare facilities receiving Medicare and Medicaid reimbursement to (a) recognize advance directives, (b) ask clients whether they have advance directives, and (c) provide educational materials advising clients of their rights to declare their personal wishes regarding treatment decisions, including the right to refuse medical treatment. 19.When is an autopsy required by law? An autopsy or postmortem examination is an examination of the body after death. It is performed only in certain cases. The law describes under what circumstances an autopsy must be performed, for example, when death is sudden or occurs within 48 hours of admission to a hospital. The organs and tissues of the body are examined to establish the exact cause of death, to learn more about a disease, and to assist in the accumulation of statistical data. 20.Who can certify that a client is dead? The formal determination of death, or pronouncement, must be performed by a primary care provider, a coroner, or a nurse. The granting of the authority NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation to nurses to pronounce death is regulated by the state. It may be limited to nurses in long-term care, home health, and hospice agencies or to advanced practice nurses. 21.Describe: DNR, AND, Euthanasia A DNR order is generally written when the client or proxy has expressed the wish for no resuscitation in the event of a respiratory or cardiac arrest. Primary care providers may order “no code” or “do not resuscitate” (DNR) for clients who are in a stage of terminal, irreversible illness or expected death. Euthanasia is the act of painlessly putting to death people suffering from incurable or distressing disease. It is sometimes referred to as “mercy killing.” Regardless of compassion and good intentions or moral convictions, euthanasia is legally wrong in the United States and can lead to criminal charges of homicide or to a civil lawsuit for withholding treatment or providing an unacceptable standard of care. 22.Discuss differences between:  a felony and a misdemeanor A felony is a crime of a serious nature, such as murder, punishable by a term in prison. A misdemeanor is an offense of a less serious nature and is usually punishable by a fine or short-term jail sentence, or both.  Negligence and Malpractice Negligence is misconduct or practice that is below the standard expected of an ordinary, reasonable, and prudent individual. Such conduct places another individual at risk for harm. Malpractice is “professional negligence,” that is, negligence that occurred while the individual was performing as a professional. Malpractice applies to primary care providers, dentists, and lawyers, and generally includes nurses. 23.List and describe the six elements necessary to prove malpractice. Duty. The nurse must have (or should have had) a relationship with the client that involves providing care and following an acceptable standard of care. Breach of duty. There must be a standard of care that is expected in the specific situation but that the nurse did not observe. Foreseeability. A link must exist between the nurse’s act and the injury suffered. Causation. It must be proved that the harm occurred as a direct result of the nurse’s failure to follow the standard of care and that the nurse could have (or should have) known that failure to follow the standard of care could result in such harm. Harm or injury. The client or plaintiff must demonstrate some type of harm or injury (physical, financial, or emotional) as a result of the breach of duty owed the client. NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation Damages. If professional negligence caused the injury, the nurse is held liable for damages that may be compensated. 24.Intentional Torts: Assault, Battery, False Imprisonment, Invasion of Privacy, Defamation of Character: Libel, Slander. Know examples of each.  Box 3.11 Examples of HIPAA Compliance 25.Describe each: Loss of Client Property, such as jewelry, money, eyeglasses, and dentures, is a constant concern for hospital personnel. Nurses are expected to take reasonable precautions to safeguard a client’s property, and they can be held liable for its loss or damage if they do not exercise reasonable care. Unprofessional Conduct, According to most nurse practice acts, unprofessional conduct is considered one of the grounds for action against a nurse’s license. Unprofessional conduct includes incompetence or gross negligence, conviction for practicing without a license, falsification of client records, and illegally obtaining, using, or possessing controlled substances. 26.How does the Good Samaritan Act protect the registered nurse? Laws designed to protect healthcare providers who provide assistance at the scene of an emergency against claims of professional negligence unless it can be shown that there was a gross departure from the normal standard of care or willful wrongdoing on their part. Guidelines for nurses who choose to render emergency care are as follows: Limit actions to those normally considered first aid, if possible. Do not perform actions that you do not know how to do. Offer assistance, but do not insist. Have someone call or go for additional help. Do not leave the scene until the injured individual leaves or another qualified individual takes over. Do not accept any compensation. 27.When should the nurse question a physician’s order? Question any order a client questions (Patient Advocacy). For example, if a client who has been receiving an intramuscular injection tells the nurse that the healthcare provider changed the order from an injectable to an oral medication, the nurse must recheck the order before giving the medication. Question any order if the client’s condition has changed. The nurse is considered responsible for notifying the primary care provider of any significant changes in the client’s condition, whether the primary care provider requests notification or not. Question and record verbal orders to avoid miscommunications. In addition to recording the time, the date, the primary care provider’s name, and the orders, the nurse documents the circumstances that occasioned the call to the primary care provider, reads the orders back to the primary care NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation provider, and documents that the primary care provider confirmed the orders as the nurse read them back. Question any order that is illegible, unclear, or incomplete. Misinterpretations in the name of a drug or in dose, for example, can easily occur with handwritten orders. 28.Read the section: Practice Guidelines: Legal Protection for Nurses II. Values, Ethics, and Advocacy: Chapter 4 1. Compare and contrast values, beliefs, and attitudes. Beliefs (or opinions) are interpretations or conclusions that people accept as true. They are based more on faith than fact. Beliefs do not necessarily involve values. Attitudes are mental positions or feelings toward an individual, object, or idea (e.g., acceptance, compassion, openness). Typically, an attitude lasts over time, whereas a belief may last only briefly. Values are learned through observation and experience. As a result, they are heavily influenced by an individual’s sociocultural environment that is, by societal traditions; by cultural, ethnic, and religious groups; and by family and peer groups. 2. How are values learned? Values are learned through observation and experience. 3. Review Box 4.1 Essential Nursing Values. 4. Values Clarification Process:  What are the three steps? Choosing Beliefs are chosen Freely, without outside pressure From among alternatives After reflecting and considering consequences. Prizinig Chosen beliefs are prized and cherished. Acting Chosen beliefs are Affirmed to others Incorporated into one’s behavior Repeated consistently in one’s life.  Why is values clarification important for the nurse? for the client? Nurse Value clarification is important to the nurse due to the different types of clients they will be responsible for caring for. Their fundamental chosen beliefs may come in stark contrast of a client. The nurse has to be able to set aside personal beliefs to assist and take care of clients. NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation  Client To plan effective client-centered care, nurses need to identify clients’ values as they influence and relate to a particular health problem. How can the nurse best help the client to clarify their values? The nurse should never assume that the client has any particular values. Rather, the nurse explores client values through discussion. As described in the QSEN competencies, clients’ values, and thus their preferences, are assessed and used in each step of nursing care, including the communication of these values to other members of the healthcare team. 5. Describe: Ethics, Morals, Bioethics Ethics has several meanings in common use. It refers to (a) a method of inquiry that helps people to understand the morality of human behavior (i.e., it is the study of morality), (b) the practices or beliefs of a certain group (e.g., medical ethics, nursing ethics), and (c) the expected standards of moral behavior of a particular group as described in the group’s formal code of professional ethics. Bioethics is ethics as applied to human life or health (e.g., to decisions about abortion or euthanasia). Morality (or morals) is similar to ethics, and many people use the terms interchangeably. Morality usually refers to private, personal standards of what is right and wrong in conduct, character, and attitude. 6. List and describe the different types of moral theories/frameworks. Consequence-based (teleological) theories look to the outcomes (consequences) of an action in judging whether that action is right or wrong. Principles-based (deontological) theories involve logical and formal processes and emphasize individual rights, duties, and obligations. Relationships-based (caring) theories emphasize courage, generosity, commitment, and the need to nurture and maintain relationships. 7. Describe and give an example of each moral rule applicable to the nurse. Autonomy refers to the right to make one’s own decisions. Nurses who follow this principle recognize that each client is unique, has the right to be him- or herself, and has the right to choose personal goals. Nonmaleficence is the duty to “do no harm.” Although this would seem to be a simple principle to follow, in reality it is complex. Harm can mean intentionally causing harm, placing someone at risk of harm, and unintentionally causing harm. In nursing, intentional harm is never acceptable. However, placing someone at risk of harm has many facets. A client may be at risk of harm as a known consequence of a nursing intervention that is intended to be helpful. For example, a client may react adversely to a medication. Unintentional harm occurs when the risk could not have been anticipated. For example, while catching a client who is falling, the nurse grips the client tightly enough to cause bruises to the client’s arm. NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation Beneficence means “doing good.” Nurses are obligated to do good, that is, to implement actions that benefit clients and their support individuals. However, doing good can also pose a risk of doing harm. For example, a nurse may advise a client about a strenuous exercise program to improve general health, but should not do so if the client is at risk of a heart attack. Justice is frequently referred to as fairness. Nurses often face decisions in which a sense of justice should prevail. For example, a nurse making home visits finds one client tearful and depressed, and knows she could help by staying for 30 more minutes to talk. However, that would take time from her next client, who has diabetes and needs a great deal of teaching and observation. The nurse will need to weigh the facts carefully in order to divide her time justly among her clients. Fidelity means to be faithful to agreements and promises. By virtue of their standing as professional caregivers, nurses have responsibilities to clients, employers, government, and society, as well as to themselves. Nurses often make promises such as “I’ll be right back with your pain medication” or “I’ll find out for you.” Clients take such promises seriously, and so should nurses. Veracity refers to telling the truth. Although this seems straightforward, in practice, choices are not always clear. Should a nurse tell the truth when it is known that it will cause harm? Does a nurse tell a lie when it is known that the lie will relieve anxiety and fear? Lying to sick or dying people is rarely justified. The loss of trust in the nurse and the anxiety caused by not knowing the truth, for example, usually outweigh any benefits derived from lying. Accountability means “answerable, or to give an account or defense to oneself and others for one’s own choices, decisions and actions as measured against a standard.” Responsibility refers to “the blameworthiness or praiseworthiness that one bears for one’s conduct or the performance of duties” 8. Codes of Ethics  Purposes Is a formal statement of a group’s ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession. Nurses are responsible for being familiar with the code that governs their practice.  ANA Code of Ethics: What are the Guidelines? How are these applicable in the day-to-day client care setting? a. Remember that the standards of professionalism (e.g., an ethical and legal obligation to maintain client privacy and confidentiality at all times) are the same online as in any other circumstance. b. Do not take photos or videos of clients on personal devices, including cell phones. c. Maintain professional boundaries when using electronic media. NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation d. Do not transmit or place online individually identifiable client information. e. Report any identified breach of confidentiality or privacy. 9. Making Ethical Decisions: Box 4.5 Application of a Bioethical Decision-Making Model  What are the steps in resolving an ethical dilemma? 1. Identify the moral aspects. 2. Gather relevant facts that relate to the issue. 3. Determine ownership of the decision. 4. Clarify and apply personal values. 5. Identify ethical theories and principles. 6. Identify applicable laws or agency policies. 7. Use competent interdisciplinary resources. 8. Develop alternative actions and project their outcomes on the client and family. 10.How can a nurse enhance their ethical decision-making ability? Become aware of your own values and the ethical aspects of nursing. Be familiar with nursing codes of ethics. Seek continuing education opportunities to stay knowledgeable about ethical issues in nursing. Respect the values, opinions, and responsibilities of other healthcare professionals that may be different from your own. Participate in or establish ethics rounds. Ethics rounds use hypothetical or real cases that focus on the ethical dimensions of client care rather than the client’s clinical diagnosis and treatment. Serve on institutional ethics committees. Strive for collaborative practice in which nurses function effectively in cooperation with other healthcare professionals. 11.Review the different types of end-of-life issues: euthanasia and assisted Suicide, termination of life-sustaining treatment, withholding food and fluids. What is the nurse’s role in these situations? The nurse should recall that legality and morality are not the same thing. Determining whether an action is legal is only one aspect of deciding whether it is ethical. The questions of suicide and assisted suicide are still controversial in Western society. The ANA’s position statement on assisted suicide and active euthanasia (2013) states that both active euthanasia and assisted suicide are in violation of the Code of Ethics for Nurses. III. Documenting and Reporting: Chapter 14 1. What are purposes of client records: Client record, is a formal, legal document that provides evidence of a client’s care and can be written or computer based. NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation 2. Discuss the different types of documentation systems. Source-oriented record. Each healthcare provider or department makes notations in a separate section or sections of the client’s chart. Problem-oriented medical record (POMR), or problem- oriented record (POR), established by Lawrence Weed in the 1960s, the data are arranged according to the problems the client has rather than the source of the information. Members of the healthcare team contribute to the problem list, plan of care, and progress notes. Plans for each active or potential problem are drawn up, and progress notes are recorded for each problem. PIE documentation model groups information into three categories. PIE is an acronym for problems, interventions, and evaluation of nursing care. This system consists of a client care assessment flow sheet and progress notes. Focus charting is intended to make the client and client concerns and strengths the focus of care. Three columns for recording are usually used: date and time, focus, and progress notes. The focus may be a condition, a nursing diagnosis, a behavior, a sign or symptom, an acute change in the client’s condition, or a client strength. The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR. Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Computerized Documentation, EHRs are used to manage the huge volume of information required in contemporary healthcare. That is, the EHR can integrate all pertinent client information into one record. Nurses use computers to store the client’s database, add new data, create and revise care plans, and document client progress. Case management model emphasizes quality, cost-effective care delivered within an established length of stay. This model uses a multidisciplinary approach to planning and documenting client care, using critical pathways. 3. What are the different types of flow sheets? Graphic Record, This record typically indicates body temperature, pulse, respiratory rate, blood pressure, weight, and, in some agencies, other significant clinical data such as admission or postoperative day, bowel movements, appetite, and activity. Intake and Output Record, All routes of fluid intake and all routes of fluid loss or output are measured and recorded on this form. Medication Administration Record, Medication flow sheets usually include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route, and the nurse’s signature. Skin Assessment Record, A skin or wound assessment is often recorded on a flow sheet. This EHR specifically utilizes the Braden Assessment. EHRs may include categories related to stage of skin injury, drainage, odor, culture information, and treatments. 4. How does documentation of client care in the long-term care setting differ from documentation in the acute care setting? NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation Long-term facilities usually provide two types of care: skilled or intermediate. Clients needing skilled care require more extensive nursing care and specialized nursing skills. Requirements for documentation in long-term care settings are based on professional standards, federal and state regulations, and the policies of the healthcare agency. Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987. The OBRA law, for example, requires that (a) a comprehensive assessment (the Minimum Data Set [MDS] for Resident Assessment and Care Screening) be performed within 4 days of a client’s admission to a long-term care facility, (b) a formulated plan of care must be completed within 7 days of admission, and (c) the assessment and care screening process must be reviewed every 3 months. 5. General Guidelines for Documentation. Review each of these carefully.  Why is military time used in documentation? Avoids confusion about whether a time was a.m. or p.m.  Why is correct spelling so important in documentation? Correct spelling is essential for accuracy in recording. All entries must be legible and easy to read to prevent interpretation errors. Hand printing or easily understood handwriting is usually permissible. Follow the agency’s policies about handwritten recording.  Table 14.5 Official “Do Not Use” List; Why is it unwise to use any of these abbreviations? In 2004, The Joint Commission developed National Patient Safety Goals (NPSGs) to reduce communication errors. These goals are required to be implemented by all organizations accredited by the commission. As a result, the accredited organizations must develop a do-not-use list of abbreviations, acronyms, and symbols. This list must include those banned by The Joint Commission  How are errors corrected? When a recording mistake is made, draw a single line through it to identify it as erroneous with your initials or name above or near the line (depending on agency policy). Do not erase, blot out, or use correction fluid. The original entry must remain visible. Practice Guidelines: Documentation; Review these carefully. Do Chart a change in a client’s condition and show that follow-up actions were taken. Read the nurse’s notes prior to care to determine if there has been a change in the client’s condition. NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation Be timely. A late entry is better than no entry; however, the longer the period of time between actual care and charting, the greater the suspicion. Use objective, specific, and factual descriptions. Correct charting errors. Chart all teaching. Record the client’s actual words by putting quotes around the words. Chart the client’s response to interventions. Review your notes—are they clear and do they reflect what you want to say? Don’t Leave a blank space for a colleague to chart later. Chart in advance of the event (e.g., procedure, medication). Use vague terms (e.g., “appears to be comfortable,” “had a good night”). Chart for someone else. Record “patient” or “client” because it is their chart. Alter a record even if requested by a superior or a primary care provider. Record assumptions or words reflecting bias (e.g., “complainer,” “disagreeable”). 6. Describe the information found in Box 14.3 Key Elements for Effective Handoff Communication The information in Box 14.3 outlines the guidelines for communication during handoff. The communication should include the following: Up-to-date information Interactive communication allowing for questions between the giver and receiver of client information NURS 3000 - Professional Nursing Legal and Ethical Guidelines, Documentation Method for verifying the information (e.g., repeat-back, read-back techniques) Minimal interruptions Opportunity for receiver of information to review relevant client data (e.g., previous care and treatment).