Legal Aspects of Nursing Notes III

Writing an Incident Report

-  A tool used as a means of identifying and improving client care. They are usually made

   immediately after its occurrence and validated immediately by co-workers.

-  the real purpose is to provide accurate documentation of occurrences affecting the client as

   to have basis for its intervention.

-  it is usually made as a comprehensive & accurate report on any unexpected or unplanned

   occurrence that affects or potentially affects his family or other members of the health team.

                                   

      The following are common situations that require an incident report:

                             MOST OF THEM ARE NEGLIGENT NURSING ACTS

a.    Falls , Burns & medication error

b.    Break in the aseptic technique

c.    Incorrect sponge count during surgery

d.    Failure to report the clients condition

   Rules in Incident Report

 Don’t use the word error or include lawful judgment or inflammatory words

Legal Rules on Documentation, Charting & MD’s Order

Documentation

- Legally required by accrediting agencies, state licensing laws and state nurse and medical

  practice acts.

-required for insurers reimbursement

- legal documentation that signifies proper communication about the patients condition

Question: What should be written in the nurses notes?

            All facts and information regarding the patients condition, treatment, care, progress and

     response to illness and treatment.

            Document consent or refusal of treatment.

Question:    How should data be recorded? Entries should:

1.    State date and time given.

2.    be written, signed & titled by caregiver or supervisor who observed action

3.    follow chronological sequence

4.    Be accurate, factual, objective, complete , precise and clear

5.    Use universal abbreviations. Example: prn, b.c.

6.    be legible; black pen

7.    Have all spaces filled in, leave no blank spaces.

8.    Avoid judgmental or evaluative statements such as “ uncooperative client”

9.    Do not document for others or change documentation for other individuals

Question: Should I accept verbal phone orders from an MD?

            Generally, NO. Specifically, follow your hospitals by laws, regulations and policies regarding this. Failure to follow the hospital’s rules could be considered NEGLIGENCE.

            In cases when verbal orders are deemed necessary the following outline may find helpful

                                    REGARDING TELEPHONE ORDERS:

1.    date and time entry

2.    repeat the order to the MD & record the order

3.    sign the order, begin with t.o. ( telephone order), write the MD’s name & then signature the order

4.    if another nurse witnesses the order, that signature follows

5.    The physician needs to countersign the order within the time frame according to hospital or agency policy. 

Question: Should I follow an MD’s order if I know it is wrong? ]

            No. If you think a reasonable prudent nurse would not follow it; but first inform the MD and record your decision. Report it to your supervisor.

            Should I follow an MD’s order if I disagree with his or her judgment?

            Yes. Because the law does not allow you to substitute your nursing judgment for a doctors medical judgment. Do record that you questioned the order and that the doctor confirmed it before you carried it out. In order to be safe, check the agency policy manual of your work.

Question: What can I do if the MD delegates a task to me for which I am not prepared?

            Inform the MD of your lack of medication and experience in performing the task. Refuse to do it. If you inform him or her and still carry out the task, both you and the MD could be considered NEGLIGENT if the patient is harmed by it. If you do not tell the MD and carry out the task, you are solely liable.

                                           Liability for Mistakes

Question:  Is the hospital or the nurse liable for the mistakes made by the nurse while following orders?  Both the nurse and hospital can be sued for damage if a mistake made by the nurse injures the patient. The nurse is responsible for his or her own actions. The hospital would be liable, based on the doctrine of Respond eat Superior.

Question: For what would I be liable if I voluntarily stopped to give care at the scene of an accident?  The GOOD SAMARITAN ACT – protects health practitioners against malpractice claims resulting from assistance provided at the scene of an emergency ( UNLESS THERE WAS WILLFUL DOING) as long as the level of care provided is the same way as any other reasonably prudent person would give under similar circumstances. It also encouraged health care professionals to assist in emergency situations without fear of being sued for the care provided. These laws limit liability and offer legal immunity for people helping in an emergency, providing they give reasonable care. 

                                                                                                                                               

                                             Organ Donation

Requirements:

1. Any person 18 years of age or older may become an organ donor by written consent.
2. Informed choice to donate an organ can take place with the use of a written document signed by the client prior to death, a will, or a donor card or an advance directive.
3. In the absence of appropriate documentation, a family member or legal guardian may authorize donation on the descendant’s organs.
4. In case of newborns, they must be full term already ( more than 200 grams)

Laws that Protect potential donors to Expedite acquisition:

1.    National Organ Transplant Act: prohibit selling of organs

2.    Uniform Anatomical Act: guidelines regarding who can donate, how donations are to

Be made, and who can receive donated organs.

3.    Uniform Determination Death Act: Legal determination of brain death ( absence of

       breathing movement, cranial nerve reflex,  response to any painful stimuli and cerebral

       blood flow and flat EEG.

Management of Donor

1.    Maintain body temperature at GREATER than 96.8 F with room temperature at 70 -80 F warming blankets, warmer for IV fluids.

2.    Maintain greater than 100% PaO2 and suction/ turn & use (PEEP) positive End expiratory pressure to prevent hypoxemia caused by airway obstruction & pulmonary edema.

3.    Maintain CVP (Central Venous Pressure) at 8 to 10 mm Hg and systolic blood pressure at greater than 90 mm Hg to prevent Hypotension.

4.    Maintain Fluid & Electrolyte balance due to volume depletion

5.    Prevent infections due to invasive procedures.

Religions that have different views regarding organ donations

1. Russian Orthodox: permits all donations EXCEPT THE HEART.
2. Jehovah’s Witness: DOES NOT ALLOW organ donation and all organ to be

                                         transplanted must be drained of blood first.

3. Judaism: They permit organ donation as long as with RABBINICAL CONSULTATION.
4. Islam: will NOT USE ORGAN STORED IN ORGAN BANKS.

                                                                                                                                                           

                    Do not Resuscitate (DNR)

Factors in giving order of resuscitation:

1. Client’s will and advance directives

2.  Disease Prognosis such as cancer or HIV

3. Client/s ability to cope

4. Whether CPR will be given or not

Reasons for refusing to perform resuscitation

1. Epidemic or widespread disease or debilitating condition & that CPR is not beneficial
2. CPR will aggravate or prolong the agony of the client
3. against cultural & religious suffering
4. Advance directives & Will

                                                                                                                                               

Voluntary Admission versus Involuntary Admissions

Voluntary Admissions:

Requirements & By Laws

1. Lawful or of legal age
2. If the client is too ill, a guardian is possible
3. Client agrees to accept the treatment
4. The client is free  to sign him or herself out of the hospital- Has the right to demand & receive RELEASE.

 Involuntary Admissions

                              Requirements & By Laws

1. Deemed necessary for the following reasons & criteria:
1. Danger to self & others
2. need psychiatric or physical care
3. State laws have been determined legally by the state
2. The client who is involuntarily admitted does not lose his or her right of informed

       consent.

 Question: What is the meaning of Conditional Release?

-          usually requires outpatient treatment for a specified period of time to determine the

      client’s compliance with medication protocol , ability to meet basic needs and ability

      to reintegrate to community.         

        

                                   Other Laws to be Remembered

Tarasoff Act- if there are manifestations that a patient has some suicidal tendencies, it is the duty on the part of the nurse of a threatened suicide or possible harm or threat to others. There must be the proper dissemination of information to other members of the health care team.

Occupational Safety & Health Act- requires that an employer provide a safe work place for employees according to regulations. Employees can confidentially report UNSAFE WORKING CONDITIONS that violate regulations.  A PERSON WHO DOES NOT REPORT UNSAFE WORKING CONDITIONS CAN BE RETALIATED AGAINST BY THE EMPLOYER.

M’Naghten Rule (1832) - a person is guilty if:

a.    person did not know the nature and quality of the act

b.    Person could not distinguish right from wrong, if the person does not know what she / he is doing or a person does not know it was wrong.

Irresistible Impulse Test (used together with M,Naghten Rule) – person knows right from wrong, but:

a.    Driven by impulse to commit criminal acts regardless of consequences.

b.    Lack premeditation in sudden violent behavior.