CCST4079_NF_Session 9_Legal Issues Documentation

The essential elements of informed consent include:

1. Competence: The patient must be capable of making the decision.
2. Disclosure: The healthcare provider must provide all relevant information about the procedure, risks, benefits, and alternatives.
3. Understanding: The patient must understand the information provided.
4. Voluntariness: The decision must be made freely without coercion.
5. Consent: The patient must give explicit permission for the procedure.

Nurses can minimize their chances of liability by:

1. Adhering to Standards of Care: Following established protocols and guidelines.
2. Maintaining Accurate Documentation: Keeping detailed and accurate records of patient care.
3. Obtaining Informed Consent: Ensuring patients understand procedures and risks.
4. Continuing Education: Staying updated on best practices and legal responsibilities.
5. Effective Communication: Clearly communicating with patients and the healthcare team.

Nurses have the legal responsibility to:

• Provide care that meets the accepted standards of practice in their field.
• Stay informed about current laws and regulations affecting nursing practice.
• Report any unsafe practices or conditions that could harm patients.
• Ensure that they are competent to perform the tasks they undertake.

1. Common law: Based on court decisions and precedents.
2. Criminal law: Protects society with punishments such as fines or imprisonment.
3. Civil action: Involves disputes between individuals, typically resulting in compensation.

A crime is defined as an act committed in violation of public (criminal) law, which is punishable by a fine or imprisonment. It does not have to be intended in order to be classified as a crime.

A nurse who administers a lethal overdose may be charged with manslaughter or second-degree murder.

A nurse who hits a client may be charged with assault or battery.

A Tort is a civil wrong against a person or a person's property, based on fault, which can involve something done incorrectly or omitted.

The two main categories of Torts are:

1. Intentional Torts: Acts done deliberately that cause physical or psychological harm.
2. Non-intentional Torts: Includes negligence (conduct that falls below the standard of care) and malpractice (professional negligence), which do not involve intention but have an element of harm.

Assault involves an intentional act that creates a reasonable apprehension of imminent harmful or offensive contact, while battery is the actual physical act of causing harmful or offensive contact with another person without their consent.

False imprisonment occurs when a person is confined or restrained against their will without legal justification. This can involve physical barriers, threats, or improper use of authority.

Invasion of privacy refers to the violation of a person's right to keep their personal information private. This can include unauthorized access to personal data, public disclosure of private facts, or intrusion into personal space.

Defamation involves making a false statement about someone that injures their reputation. It can be categorized into libel (written statements) and slander (spoken statements). The statement must be made to a third party and must not be protected by privilege.

Assault is an attempt or threat to touch unjustifiably, and it does not require physical contact. An example is threatening to give an injection without consent.

Battery is the willful, intentional touching of another person without their consent. It may or may not cause harm, which can be physical injury or be offensive to dignity. Examples include giving treatment without consent or a nurse hitting a client.

False imprisonment is defined as unjustifiable detention without legal authority. This can occur in situations such as:

1. Keeping a patient in the hospital against their will.
2. Using restraints without proper consent or order.

A direct violation of personal rights in healthcare includes actions such as:

1. Publishing a client's photo in a hospital without consent.
2. Releasing a client's medical information to unauthorized persons, such as the press or an employer.
3. Case example: The 梁愛詩案, where patient privacy was disclosed to the media.

Slander is a form of defamation that occurs through spoken words. It involves making false statements that harm a person's reputation.

Libel refers to defamation that occurs through print, writing, or pictures. It involves making false statements in a permanent form that can damage a person's reputation.

Defamation of character involves the publication of false statements that damage a person's reputation. In nursing, this can occur through spoken statements (slander) or written statements (libel). For example, if a nurse claims that the parents of a child client do not care, this could be considered slander, making the nurse liable for defamation.

1. Alleged defamatory statements about a supervisor in a nurse's resignation letter.

2. Alleged defamation of character when hospital staff question a parent about suspected sexual abuse.

3. A lawsuit by a nurse against an employer for wrongful dismissal and defamation of character.

4. A lawsuit alleging that a nurse released untrue and defamatory client information.

Negligence is a type of unintentional tort characterized by misconduct or practice that falls below the standard of a reasonable, prudent person, creating a risk of harm to another individual. It applies to anyone, not just professionals.

An example of negligence is when a mother leaves her 5-year-old child at home alone while she goes to play mahjong, which puts the child at risk.

Malpractice is defined as negligence that occurs while a person is performing as a professional, applicable to various professions such as physicians, dentists, lawyers, and nurses.

The key elements of malpractice include:

1. Breach of duty
2. Foreseeability
3. Causation
4. Harm or injury
5. Damages

Negligence in nursing is the failure to take the care that a reasonable nurse in similar circumstances would have taken. It requires proving certain elements in court.

The first element is the duty of care, which arises from a person's reliance on a nurse's knowledge and expertise, creating a legal obligation for the nurse to provide reasonable care.

A breach of the standard of care is determined by what constitutes reasonable nursing care in the circumstances, based on evidence such as:

1. Patient's chart
2. Professional standard of practice
3. Institutional policies
4. Testimony about the availability of equipment and personnel

The plaintiff must prove that actual harm was suffered and that this harm was caused by the nurse's negligent acts or omissions. If the harm could not have been reasonably anticipated, the nurse will not be held liable.

A court will not find negligence if there was no harm, even if the nurse's act or omission breached the standard of care, or if the harm would have occurred regardless of the nurse's breach.

A damages award is the amount of compensation ordered by the court to be paid to the plaintiff by the negligent defendant, provided the plaintiff has proved the elements of negligence and the value of the losses suffered.

A duty of care exists when the patient has a right to rely on the staff for quality and competent care.

Yes, a nurse who passes by and sees a patient having a medical emergency has a duty of care to assist the patient, regardless of assignment.

The appropriate standard of care in nursing refers to the level of care that a reasonably competent nurse would provide under similar circumstances. It is determined by considering:

1. Professional guidelines: Standards set by nursing organizations and regulatory bodies.
2. Legal precedents: Previous court cases that establish benchmarks for care.
3. Expert testimony: Insights from experienced professionals in the field.
4. Institutional policies: Specific protocols and procedures established by healthcare facilities.

To determine if a nurse is in breach of the duty of care, the following criteria are typically evaluated:

1. Existence of a duty: Establishing that a nurse had a legal obligation to provide care.
2. Breach of duty: Demonstrating that the nurse failed to meet the standard of care expected in the situation.
3. Causation: Proving that the breach of duty directly caused harm to the patient.
4. Damages: Showing that the patient suffered actual harm or injury as a result of the breach.

The legal guidelines for nursing practice are defined by:

1. Nursing committees within the HA
2. The nursing council of HK
3. Professional and specialty nursing organizations (e.g. HK Association of Critical Care Nurses)
4. Written policies and procedures of healthcare institutions

Harm must be foreseeably caused by the nurse’s act or omission. A nurse is liable only if the harm was predictable and a direct result of the breach of duty.

To promote patient safety and risk management.

1. HA Risk Alert
2. Medication Incident Reporting Program

To reduce medication errors by providing clear guidelines on abbreviations that should not be used.

• Wrong Part
• Retained Instruments/Material
• In-Patient Suicide

The importance of engaging clinical teams in patient safety and fostering a safety culture through staff commitment and feedback.

Mr. Wong was in the post-operative ward following a gall-bladder operation and became very agitated during the night. His bed was far from the nursing station, and there was no restraint jacket available.

Mr. Wong fell and sustained a fracture of his right femur due to the incident.

Yes, by virtue of the nurse-patient relationship, a nurse owes a duty of care to her patients.

Whether Ada is in breach of that duty of care will be determined based on established legal principles.

This will depend on the specific circumstances surrounding the breach and the harm that occurred.

The determination of actual injury will require an assessment of the consequences of Ada's actions.

Ada owed a duty of care to ensure the safety and well-being of the client during their care.

A breach of duty occurs when a nurse fails to meet the standard of care, such as not pulling up the bed side rail to prevent falls for post-operative elderly patients.

The outcome of the nurse's breach of duty was that the client was injured, specifically suffering a fracture.

The client's injury was directly caused by the nurse's failure to carry out the duty of care, which included maintaining safety measures like bed side rails.

Checking the placement of a Ryle's tube is crucial to ensure that the tube is correctly positioned in the stomach and not in the lungs. Failure to do so can lead to serious complications, such as aspiration pneumonia, which can be fatal, especially in vulnerable populations like infants.

Factors that determine malpractice include:

1. Duty of Care: The nurse had a duty to ensure the tube was correctly placed.
2. Breach of Duty: If the nurse did not adequately check the placement, this could be a breach.
3. Causation: The nurse's actions must be directly linked to the baby's death.
4. Damages: The outcome (the baby's death) must be a result of the breach of duty.
   If the nurse can prove that she followed proper protocols and the tube was indeed placed correctly, she may not be charged with malpractice.

The nursing standard of care is used to measure nursing conduct and determine whether the nurse acted as a reasonably prudent nurse would under the same or similar circumstances.

A breach of the nursing standard of care is one of the elements that must be proven in a malpractice lawsuit.

In a case of negligence, the plaintiff must prove the following:

1. Duty of care owed to the patient
2. Breach of duty owed to the patient
3. Foreseeability / causation
4. Injury / damages

1. Function within the scope of education, job description, and nurse practice act.

2. Follow the organization's procedures and policies.

3. Build and maintain a good rapport with clients.

4. Always check the client's identity.

5. Observe and monitor the client's condition.

6. Accurately communicate and record significant changes.

7. Update in good practice.

8. Promptly and accurately document all assessments and care.

The 5 Rights of medication administration are:

1. Right medication
2. Right dose
3. Right route
4. Right time
5. Right client

Reporting all incidents is crucial to:

• Ensure patient safety
• Identify and address systemic issues
• Facilitate quality improvement
• Protect against liability

If a nurse receives a questionable order, they should:

1. Always check the order for clarity
2. Verify with the prescribing provider if necessary
3. Document any concerns and actions taken

Nurses can maintain clinical competence by:

• Engaging in continuing education
• Participating in professional development activities
• Staying updated with evidence-based practices
• Seeking feedback on their performance

Knowing one's own strengths and weaknesses is significant because it helps nurses to:

• Enhance their skills in areas of strength
• Seek assistance or training in areas of weakness
• Improve overall patient care and safety

The purpose of informed consent is to provide the client with complete information prior to obtaining their agreement to accept a course of treatment, ensuring that the decision is made based on the principle of autonomy.

1. Voluntary Consent: Must be given without coercion or pressure.

2. Mental Competence: Consent must be provided by a patient or legal proxy who is mentally competent to understand the information.

3. Information Processing: The patient must be able to receive, retain, and weigh information about the procedure, including risks, benefits, and alternatives.

4. Personal Values: The decision must reflect the patient's own values, preferences, and goals.

5. Sufficient Time: Patients should be given sufficient time to consider and consult before making a decision.

• Minors (under 18 years old)
• Unconscious patients or those too injured to consent
• Mentally ill or cognitively impaired persons judged incompetent by professionals

In these cases, consent must be obtained from a parent, legal guardian, or legal representative.

In an emergency, medical treatment may be given without consent as it is a rule of common law, applicable when a person is unable to consent and treatment is in their best interests.

Emergency consent is valid when:

1. The patient is unconscious or unable to consent in life-threatening or critical condition.
2. No minor consent form can be obtained.
3. The emergency consent form can be signed by two doctors.

The consent must be read aloud to the client, or an interpreter must be provided to ensure understanding.

The nurse must ensure that the patient truly understands the consent form before signing.

Implied consent occurs when a person's non-verbal behavior indicates agreement to a procedure, such as positioning their arm for an injection or cooperating during vital sign checks.

Nurses must always ask for verbal consent before any procedure and should not assume implied consent without confirming it verbally.

Measures include:

1. Access controls - Limiting access to authorized personnel only.
2. Data encryption - Protecting data through encryption methods.
3. Regular audits - Conducting audits to ensure compliance with security protocols.
4. Training - Providing training for staff on confidentiality policies.
5. Secure backups - Ensuring data is backed up securely to prevent loss.

Purposes for client records include:

1. Documentation of care - Providing a detailed account of patient care.
2. Communication - Facilitating communication among healthcare providers.
3. Legal protection - Serving as legal evidence in case of disputes.
4. Quality assurance - Supporting quality improvement initiatives.
5. Research - Providing data for clinical research and studies.

Guidelines include:

1. Accuracy - Ensure all entries are accurate and truthful.
2. Timeliness - Document information promptly after care is provided.
3. Clarity - Use clear and concise language to avoid misunderstandings.
4. Objectivity - Record facts without personal bias or opinion.
5. Confidentiality - Maintain confidentiality of patient information at all times.

Prohibited items include:

1. U (for unit) - Can be mistaken for zero or four.
2. Q.D. (for daily) - Can be mistaken for each other.
3. Trailing zeros - E.g., 1.0 mg can be mistaken for 10 mg.
4. MS (for morphine sulfate) - Can be mistaken for magnesium sulfate.
5. < and > - Can be mistaken for each other; use 'greater than' or 'less than' instead.

Essential guidelines include:

1. Be factual - Report only what you observe or know.
2. Use standard terminology - Avoid jargon and use accepted medical terms.
3. Be concise - Keep reports brief and to the point.
4. Prioritize information - Report critical information first.
5. Document changes - Note any changes in the client's condition promptly.

• Access to records for education/research must follow strict ethical and legal codes.
• Protect privacy by avoiding use of names or identifiable statements.
• Use passwords and never share them.
• Never leave a computer terminal unattended after logging on.
• Do not leave client information displayed on screen.
• Shred all unneeded computer-generated worksheets.
• Follow facility policy for correcting entry errors.
• Follow agency procedures for documenting sensitive materials.
• Use technical safeguards such as firewalls.

The primary purposes of nursing recording include:

1. Communication - Facilitates sharing of information among healthcare providers.
2. Planning client care - Aids in developing and implementing care plans tailored to individual needs.
3. Auditing health agencies - Supports quality assurance and compliance with standards.
4. Research - Provides data for studies and evidence-based practice.
5. Education - Serves as a resource for training and educating healthcare professionals.
6. Reimbursement - Essential for billing and insurance claims.
7. Legal documentation - Acts as a legal record of care provided.
8. Health care analysis - Enables evaluation of health outcomes and service effectiveness.

A Kardex is a concise method of organizing and recording client data, providing quick access to essential information such as:

• Allergies
• Medications (including IV fluids)
• Daily treatments and procedures
• Diagnostic tests
• Physical needs to be met
• Nursing goals

The types of flow sheets used in nursing documentation include:

1. Graphic record - A visual representation of patient data over time.
2. Intake and output - A record of all fluids taken in and expelled by the patient.
3. Medication administration record - A detailed log of medications administered to the patient.
4. Skin assessment record - A documentation of skin condition and assessments made during care.

Progress notes should provide information about the progress being made towards achieving desired outcomes.

Progress notes should include information about clients' problems and the nursing interventions implemented.

The nursing discharge or referral summary must include the following components:

1. Client's physical, mental, and emotional status
2. Resolved health problems
3. Treatments that need to continue
4. Current medications
5. Activity, diet, and bathing restrictions
6. Functional / self-care abilities
7. Comfort level
8. Support network
9. Health education provided
10. Discharge destination
11. Type of referral services arranged

The Clinical Management System (CMS) is an integrated electronic health record system that combines information from various healthcare providers, allowing real-time access to patient data across hospitals, thereby improving continuity of care, accuracy, and efficiency.

The key factors include:

1. Date and time - Ensure accurate recording of when the documentation was made.
2. Legibility - Documentation must be clear and readable.
3. Accepted terminology - Use standard medical terms to avoid confusion.
4. Sequence - Document events in the order they occurred.
5. Completeness - Include all necessary information.
6. Legal prudence - Be aware of legal implications of documentation.
7. Accuracy - Ensure all information is correct and truthful.
8. Permanence - Documentation should be durable and not easily altered.
9. Correct spelling - Avoid errors in spelling to maintain professionalism.
10. Appropriateness - Ensure the content is relevant and suitable.
11. Conciseness - Be brief but comprehensive in the information provided.
12. Signature - Include the signature of the person documenting to validate the entry.

Progress notes serve as a critical component of legal documentation in nursing. They provide:

1. Evidence of Care: Documenting patient assessments, interventions, and responses to treatment.
2. Continuity of Care: Ensuring that all healthcare providers are informed about the patient's condition and treatment plan.
3. Legal Protection: Serving as a defense in case of legal disputes regarding the quality of care provided.
4. Accountability: Holding nurses accountable for the care they provide and the decisions they make.

Overall, progress notes are essential for maintaining high standards of patient care and protecting the legal rights of both patients and healthcare providers.

Effective client data reporting should be concise and include pertinent information while avoiding extraneous detail.

The different types of client data reporting include:

1. Change-of-shift report
2. Telephone reports
3. Care plan conference
4. Nursing rounds

The SBAR format is recommended for organizing a change-of-shift report, which includes:

1. Situation - Current status of the patient.
2. Background - Relevant history and context.
3. Assessment - Current condition and any significant changes.
4. Recommendation - Suggested actions or priorities for the next shift.

For new admissions, the change-of-shift report should include:

• Reason for admission
• Diagnosis
• Surgery/tests performed in the past 24 hours

Essential components to highlight in a change-of-shift report include:

• Significant changes in the patient's condition
• Exact, factual information
• Current nurse & physician orders
• Priorities of care and tasks due in the next shift

Using a verification process in change-of-shift reports ensures:

• Accuracy of the information provided
• Clarity in communication between shifts
• Reduction of errors and omissions in patient care

1. Document date and time of the report.
2. Record the name of the person giving the information.
3. Record the subject of the information received.
4. Sign the notation to confirm receipt.
5. Repeat information to ensure accuracy.

The SBAR format stands for Situation, Background, Assessment, and Recommendation. It is used to structure communication in a clear and concise manner, ensuring that all relevant information is conveyed effectively during a telephone report.

A telephone report should include the following key information:

1. Client's name and diagnosis
2. Changes in nursing assessment and vital signs compared to baseline
3. Significant lab results
4. Related nursing interventions performed
5. Your name and role in relation to the client

Documenting the date, time, and content of a telephone call is important for:

• Legal protection: Provides a record of communication.
• Continuity of care: Ensures that all team members are informed of the client's status and interventions.
• Accountability: Holds the nurse accountable for the information shared and actions taken.

Follow agency policy and know the Nursing Board's position on who can give/accept telephone or verbal orders.

Clarify any ambiguous or unclear orders with the provider.

The order must be countersigned by the provider within the timeframe specified by agency policy.

A care plan conference is a meeting where a group of nurses discusses possible solutions to specific problems of a client, allowing each nurse to offer their opinions and inviting other healthcare providers to contribute their expertise.

Nursing rounds serve multiple purposes:

1. Information Gathering: Nurses obtain information that aids in planning care.
2. Client Engagement: Provides clients the opportunity to discuss their care.
3. Care Evaluation: Evaluates the nursing care that the client has received.
4. Communication: Ensures that terms used are understandable to clients.

The key types of intentional torts relevant to nursing include:

1. Assault and Battery: Threatening or causing physical harm to a patient.
2. False Imprisonment: Unlawfully restraining a patient.
3. Invasion of Privacy: Violating a patient's confidentiality or personal space.
4. Defamation: Making false statements that harm a patient's reputation.

Negligence refers to conduct that falls below the standard of care expected in nursing, while malpractice is a specific type of negligence that occurs when a professional fails to perform their duties competently, resulting in harm to a patient.

• Negligence: General failure to meet the standard of care.
• Malpractice: Professional negligence that leads to patient harm.

The different types of consent in healthcare include:

1. Informed Consent: Requires full disclosure of risks and benefits, applicable for major procedures.
2. Minor Consent: For less significant procedures, often requires parental or guardian approval.
3. Implied Consent: Assumed consent in emergency situations where the patient is unable to provide consent.
4. Emergency Consent: Given in life-threatening situations where immediate action is required and the patient cannot consent.

The purposes of client records in nursing include:

• Documentation of Care: Provides a detailed account of patient care and treatment.
• Legal Protection: Serves as evidence in case of legal disputes.
• Continuity of Care: Ensures that all healthcare providers have access to the patient's medical history.
• Quality Improvement: Helps in evaluating the effectiveness of care and identifying areas for improvement.

The types of reporting required in nursing practice include:

1. Incident Reports: Documenting any unusual occurrences or accidents.
2. Patient Care Reports: Regular updates on patient status and care provided.
3. Mandatory Reporting: Reporting certain conditions or incidents as required by law (e.g., abuse, communicable diseases).
4. Quality Assurance Reports: Evaluating the quality of care and compliance with standards.

Read back the order to the provider to confirm accuracy.

The provider must verbally acknowledge the read-back order.

Crimes are offenses against the state or public, punishable by law, while torts are civil wrongs that cause harm or loss to individuals, leading to legal liability. Examples in nursing include:

• Crime: Administering medication without a prescription (criminal negligence).
• Tort: Failing to obtain informed consent before a procedure (negligence).