The Legal Aspects of Nursing Documentation

Introduction

We are in a society that, unfortunately, has a high amount of litigation in healthcare.  As a nurse in the healthcare system, it is our responsibility to make sure that the documentation we put in the patient's chart is complete and accurate and portrays a complete picture of care rendered. 

Task

Visit the following websites.  Find the word document on Eclass and enter your answers to the questions on this site.  Once completed, upload to eclass. 

Process

Here is a little humor....visit this site for poor documentation found in medical charts. But on the serious side, learn how not to chart:

http://www.drugstudy.md/bloopers.html

Read the article: Nurses, Negligence and Malpractice (may need to copy and paste link in a new tab)

http://www.nursingcenter.com/lnc/journalarticle?article_id=423284

and answer the following questions:

1. List the six major categories of negligence that result in malpractice lawsuits.

2. A nurse is responsible for following the standards of care.  visit this site: http://www.hg.org/article.asp?id=6237
In your own words, briefly explain what the standards of care are in nursing and a nurses respondsibility. 

Read the article: Stay out of court with proper documentation   (copy and paste link in a new tab)

Visit:  http://journals.lww.com/nursing/Fulltext/2011/04000/Stay_out_of_court_w…

and answer the following question:

3.  List 5 guidelines to follow for proper documentation  and give an explanation of each. 

Watch the following video clip and answer the questions to follow:

4.  What are the 3 documents a nurse should constantly stay up-to-date with to maintain competence in managing negligence?

5. Discuss the role of complete, accurate patient assessments and documentation of those assessments in the prevention of negligence.

6.  A nurse is going to delegate some tasks to a patient care tech.  Describe the correct action a nurse needs to take when delegating.
7.  After your review of this topic, briefly discuss what you have learned and what you will apply to your nursing career. 

Evaluation

Please upload your completed answers to Eclass for grading. 

Points per questions:

1.  6 points

2.  5 points

3.  10 points

4.  3 points

5.  6 points

6.  2 points

7.  5 points

Total:  37