chart ò Failing to document a discontinued medication ò Failing to record drug reactions or changes in the patient’s condition ò Transcribing orders improperly ò Writing illegible or incomplete records Effective Documentation ò Wrong: Communication with patient’s family began today to specify the manner in which his condition is progressing and suggest a probable consequence of that progression. ò Correct: I contacted Mr. Schneider’s wife at 1332 hours. I explained that his cardiac status was worsening and that he was being prepared for a cardiac cath procedure scheduled for 1430. Late entries ò Add late entries at first available space and as soon as possible if electronic ò Document date and time the event occurred ò Clearly identify the entry as a late one Red Flags ò Adding information ò Dating the entry ò Dates/times conflict ò Inaccurate information ò Destroying records Documentation ò Cases usually come to court a long time after the events occurred ò Nurses and other personnel usually have little or no recollection of the events surrounding the case and must rely on their documentation for what occurred. ò Do you feel like your documentation would support you in a court of law? Implications 2015 Statistics MEDICAL MALPRACTICE ò Malpractice occurs when improper, injurious, or faulty treatment of a client that results in illness or injury. Why Claims are Filed ò Upset with the System ò Devastating Injuries ò Unreasonable Expectations ò Unexpected Results Extent of Suits Sued the most Legal Role of the Nurse ò Provider of service ò Ensure that client receives competent, safe, & holistic care ò Render care by “standards of reasonable, prudent person” ò Supervise/evaluate that which has been delegated ò Documentation of care ò Maintain clinical competency Legal Negligence in Nursing ò Failure to use equipment in a responsible manner ò Failure to assess and monitor and failure to communicate ò Failure to document ò Failure to act as a patient advocate ò Performing nursing procedures incorrectly ò Failing to take appropriate precautions Responsible & Accountable ò You are responsible and accountable for your actions based on: ò Your clinical training ò Your title ò Scope of practice ò Standard of care guidelines ò Policies and procedures of your health care facility Ways to Avoid Malpractice ò Know your own strengths and weaknesses ò Evaluate your assignment ò Delegate carefully ò Exercise caution when assisting procedures ò Document the use of restraints ò Take steps to prevent falls ò Comply with laws about advance directives ò Follow hospital policies and procedures ò Keep policies and procedures up to date ò Provide a safe environment ELEMENTS OF NEGLIGENCE ò Deviation from the standard of care that results in harm to the patient ò 4 elements of negligence ò Duty to act (Nurse – Patient relationship) ò Breach of duty (SOC not followed - reasonably prudent nurse) ò Damage (Physical & Psychological) No damage no case! ò Causal connection (reasonably close connection between nurses conduct & injury) All 4 must be proven State Boards of Nursing ò NYSBON was created to “assist the Board of Regents and other departments on matters of professional licensing, disciplinary process and practice of the professions.” ò Ensure public safety from dishonest and incompetent practitioners ò Ensure that you practice within your scope of practices, SOC guidelines, and other state statues. ò Ensure that you are not impaired physically or mentally from drugs and alcohol while practicing. ò Ensure that nursing schools provide you with adequate education and clinical skills needed to provide quality care. Nursing Charges ò Most common charges brought against nurses include ò Substance abuse ò Incompetence ò Negligence State board of nursing is responsible for discipline within the profession. The Board participates in licensure, disciplinary, restoration, and moral character proceedings. All members of the State Board and the committee for professional assistance must be dedicated to the public protection,