Chapter 6

1. Define advocacy, responsibility, accountability and confidentiality and how they

relate to nursing.
Responsibility: a duty or task that you are required or expected to do
1.Guidance in protection of a patient’s rights.
2.Promotion of self-determination
3.Politically active
Accountability: accept responsibility or to account for one's actions
1.Competent practice
Confidentiality: Anything said to a nurse and other health care providers by their patients
must be held in the strictest confidence. This is a legal and ethical principle. Because of
our electronic environment, confidentiality has become a major concern.

2. Discuss The Patient Care Partnership: Understanding, Expectations, Rights and

Responsibilities

3. Explain the concept of Informed Consent

permission granted in the knowledge of the possible consequences, typically that which is
given by a patient to a doctor for treatment with full knowledge of the possible risks and
benefits.

.4. Describe the following federal statutes

:a.Americans with Disabilities Act (ADA): the Americans with Disabilities Act (ADA)
ensures access to the built environment for people with disabilities

b.Emergency Medical Treatment and Active Labor Act (EMTALA)

ensure public access to emergency services regardless of ability to pay.

c.Health Insurance Portability and Accountability Act (HIPAA)

provides data privacy and security provisions for safeguarding medical
information.

d.Patient Self-Determination Act (PSDA)

encourages everyone to decide now about the types and extent of medical care they want
to accept or refuse if they become unable to make those decisions due to illness.

e.Identify components of an Advanced Directive.

a legal document in which a person specifies what actions should be taken for their health
if they are no longer able to make decisions for themselves because of illness or

5. Describe the categories of risks identified in a health care agency.

 6. Discuss the Joint Commission’s role/mission in healthcare.
to continuously improve health care for the public, in collaboration with other
stakeholders, by evaluating health care organizations and inspiring them to excel in
providing safe and effective care of the highest quality and value.

Chapter 7
1.Discuss the purpose and use of Incident (Critical Incident) reporting
used by health care agencies to document the occurrence of anything out of the ordinary
that results in, or has the potential to result in, harm to a patient, employee, or visitor.
These reports are used for quality improvement and should not be used for disciplinary
action against staff members. They are a means of identifying risks.
2.Discuss the sources and types of law
TYPES OF LAWS
Statutory Law: created by elected legislative bodies by enactments (criminal and civil)
Common Law: based on English traditions, “judge made” laws, developed within the
court system as judicial decisions
Administrative Law: established through authority given by a legislative body
Criminal law: designed to protect society from actions that threaten its existence
(directed at individuals but considered offences against the state)Felony: (1 year to life
to death penalty)
Manslaughter: disconnecting life support systems without appropriate consent
Misdemeanor: (penalty fine or less that 1 year)Alteration of medical records
Battery (no major injury)
Civil law: concerned with legal rights and relationships that exist between private
persons
Tort: civil wrong by one person against the person or property of another
Intentional: assault, battery, false imprisonment
Unintentional: negligence
3.Discuss the following terms and give examples of each:
a. Malpractice: violation of professional standard of care that results in injury to a
patient. It has special requirements.
b. Negligence: working while under the influence of alcohol/drugs and causing a
patient’s death
c. Respondent superior: a legal doctrine which states that, in many circumstances, an
employer is responsible for the actions of employees performed within the course of their
employment
d. Slander/libel: slander: the making of defamatory statements by a transitory
representation, usually an oral representation
libel: the making of defamatory statements in a fixed or medium, such as a magazine or
newspaper
4.Define the Good Samaritan Act and how it relates to nursing.
statute that protects healthcare providers and other rescuers from being sued when they
are giving emergency help to a victim provided the person uses reasonable, prudent
guidelines for care using the resources they have available
Must be a voluntary act
Person receiving help must not object to help
Rescuer must make a good-faith effort to help
5.Describe the professional and legal regulation of nursing practice
Direct and indirect patient care services.
Care to implement ordered treatment.
Provide skin test, immunizations and withdrawal of blood from veins and arteries.
Observation of signs and symptoms of illness, reactions to treatments, general behavior
or general physical conditions, determination of abnormalities and implementation of
appropriate actions.

.6.Identify the purpose of credentialing, using as examples accreditation, licensure or

registration, and certification.
Licensure: legal permit that a government agency grants to individuals to engage
in practice of a profession and to use a particular title. Mandatory in all states
(There is a need to protect public safety/welfare, occupation clearly delineated as
a separate, distinct area for work, proper authority has been established to
assume obligations of licensing process).
Certification: voluntary practice of validating that an individual nurse met
minimum standards of nursing competence in specialty areas.
State boards ensures minimum standards of education: Accreditation/Approval of
Basic Nursing Education Programs. Legal requirement. Nursing programs can
also seek voluntary accreditation from private organizations such as NLNAC or
CCNE. Some states require both.
7.Identify grounds for suspending or revoking a license or registration.
Fraud, criminal acts, gross or ordinary negligence, physical or mental impairments, drugs
and alcohol

8.Differentiate between intentional torts (assault and battery, defamation, invasion of

privacy, false imprisonment, fraud) and unintentional torts (negligence).
Tort: civil wrong by one person against the person or property of another
Intentional: assault, battery, false imprisonment
Unintentional: negligence

9.Evaluate personal areas of potential liability in nursing.

10.Describe the roles of the nurse as defendant, fact witness, and expert witness.
Seek advice of an attorney before providing testimony (will provide support and counsel
during the legal case). The nurse should retain his or her own attorney to protect nurse's
interest.

Expert witness; 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.

11.Describe laws affecting nursing practice.

Chapter 16
1. Identify purposes of a health care record.
Improve quality of patient care.
Ensure documentation of progress.
Interdisciplinary communication.
Present an accurate picture of patient throughout the time of being in the health care
system.
Financial Billing
Research and Education
2. Discuss why communication among health team members is important.
3. Describe guidelines for effective documentation and reporting.
Any behavior changes or changes in consciousness
Any changes in physical functions
Any physical sign or symptom that is: severe, recurs or persists, abnormal, increases,
indicates a complication, is not relieved by prescribed measures, is a known danger signal
or is a sign of faulty health habitsEssential information to Essential information to
chart:chart:
Nursing interventions provided
Visits by physician or other members of the health team
Any transfer of patient from one area to another and reason
Address problems related to the Address problems related to the patient’s diagnosis and
problems patient’s diagnosis and problems identified in the patient’s care plan!identified
in the patient’s care plan

4. Describe the ethical requirements regarding confidentiality apply to nursing students.

All information about patients is considered private or confidential, whether written on
paper, saved on a computer, or spoken aloud.

5. State a major advantage and disadvantage of consumer access to medical records

6. Describe charting by exception, Focus Charting (SOAP, DART, PIE) and
Computerized nursing notes.
7. Discuss the legal requirements of documentation.
1) Do not erase, apply correction fluid or scratch out errors made while recording
2) Do not write any subjective negative comments about patient or care about other
health care professionals

3) Correct all errors promptly

4) Do not leave blank spaces in nurses notes

5) Record all entries in black ink

6) When an order is questioned, document clarification was sought

7) Chart only for yourself

8) Avoid empty, generalized phrases

9) Begin each entry with TIME and end with SIGNATURE

10) Keep DOCUMENT PASSWORD to yourself

Principal sections of POMR

8. Discuss the advantages of standardized documentation forms.
Helps improves the continuity of care
Helps to easily see where something is (ex: data is always in the same spot)
Helps to see what plans are in place (care plans- discharge plans)
9. Discuss events that require written documentation.
10. Describe the purpose and content of a change-of-shift report including the use of
SBAR.
Situation
Background
Analysis/assessment
Recommendation
SBAR
History
Purpose
Additional uses
11. Discuss the impact and issues related to computerization in documentation.
Practical Advantages Advantages
Legibility
Accuracy
Timely data
Rapid communication
Definite document accountability
Enhanced patient education
Reduced medication errors
Isuues:
Malfunction
Impersonal effect
Concern for privacy
Dissemination of inaccurate information
Limitation of standard vocabulary
Cost
12. Differentiate between the charting of; data, judgments, and conclusions.
13. Identify elements to include when documenting a patient’s discharge plan
summary of a patient’s condition and care when transferring patients from one unit,
institution, or agency to another
summarize all the patient data that caregivers need to provide immediate care.
.14. Describe acceptable abbreviations and unacceptable abbreviations, acronyms, or
symbols.
Use only accepted hospital abbreviations