legal protection of nursing services

8/11/2019 Legal Protection of Nursing Services

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LEGAL PROTECTION IN

NURSING SERVICE


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MEDICAL RECORDS

One source of information that people seek to

help them make decisions about their healthcare is their testament or medical records.

Contains the record of information pertinent tothe clients health condition.

Written Consent

In law, it is voluntary agreement with anaction proposed by another.

The person giving consent must be ofsufficient mental capacity and be inpossession of all essential information inorder to give valid consent.

.


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INFORMED CONSENT

Consent of a patient or other recipient of

services based on the principles of autonomyand privacy.

GUIDELINES FOR INFORMED CONSENT:

The person giving consent must fullycomprehend the procedure to be performed

Explain to the client the risks involve

The desired outcome

Expected complications or side effects that may

occur as a result of treatment

Alternative treatments that are available


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Consent may be given by:

A competent adult

A legal guardian or individual holding durablepower of attorney

Parent of a minor child

Court order

INCIDENT REPORT

- Records of unusual or unexpected incidents that

occur in the course of a clients treatment.

Incident reports are inadvertently disclosed to the

plaintiff are no longer considered confidential and

can be subpoenaed in court


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DOCUMENTATION

- Is any written or electronically generated

information about a client that describes the

care or services provided to the client. Health

records may be paper medical documents or

electronic documents such as electronic

medical records, faxes, emails, audio-visuals.

To protect nurses , document should be:

Factual

Legible with no erasures. Corrections should bemade with a single line drawn through the error

and initialled

Accurate and complete

Timely , completed as soon after theoccurrence as ossible


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COMMON DOCUMENTATION FORMS

Focus Charting- the nurse identifies a focus based on the

client concerns or behaviors determined during

assessment

Composed of:- DATA

- ACTION

- RESPONSE


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SOAPIE / SOAPIER CHARTINGIs a problem oriented approach to

documentation

-S- ubjective data

- O- bjective data

- A- ssessment

-P-lan

- Intervention

- E-valuation

- Revision

NARRATIVE CHARTING- -Is a method in which nursing interventions and the

impact of these interventions on client outcomesare recorded in chronological order covering a

specific time frame.-


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LEGAL GUIDELINES IN

DOCUMENTATION

1. Document fact.

2. Document all relevant information.

3. Maintain the integrity of documentation.

legal protection of nursing services

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