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56 Cards in this Set
- Front
- Back
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The chart is a
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legal record
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How often must charting be done
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every 5 minutes
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The chart provides information for
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teaching and research
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The chart establishes a
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sequence of events - cause and effect
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Lack of charting means
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lack of action
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Lack of action =
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neglect
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Altering of a chart is
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not legal
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Blackening out an entry on a chart is perceived as
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hiding
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What is an acceptable for blacking out a chart entry
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draw single line through and initial
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Why is important to chart when you enter and leave a case
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Because you don't want to be held accountable for another person's mistake
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An addendum to a chart may seem like
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the entry was added after the fact
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Vitals have been rock solid stable throughout a case - get a bogus BP - recycle cuff and ok - do you chart bastard BP reading
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no need to document bogus points
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SpO2 has been reading 99% - get bad signal for some reason and value goes to 80% - do you chart this?
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no need to document bogus points
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Pt has hx of acute MI - notice four beats of ST elevation - do you chart
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no - then you would have to document action taken to address value
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A jury will believe what you chart, not what you
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say on the stand
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It is important to document _____ data regarding conversation with HCP, family, or pt
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objective (don't place blame)
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Do not chart with
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anger or retaliation
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JACHO does not allow use of
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abbreviations
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What is the purpose of informed consent
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the patient has the right to reasonably informed participation in decisions involving his or her health care. Every adult (of sound mind) has the right to determine what happens with his or her body
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Does informed consent protect the HCP in a court of law
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not really
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Informed consent - finish this... The patient has the right to reasonably
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informed participation in decisions involving his or her health care
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Informed consent - finish this... Every adult (of sound mind) has the right
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to determine what happens with his or her own body
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Informed consent - explain "reasonable"
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something a layperson would want to know
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Natanson v. Kline (1960) - Three things required to provide to patients in obtaining pt consent
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1. Nature and purpose of proposed tx
2. Potential risks/benefits 3. Alternative tx with assoc risks/benefits |
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Information provided to obtain informed consent is considered a
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professional standard of disclosure (MD-based)
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Informed consent Natanson v. Kline case - claimed did not provide disclosure - how did court and supreme find
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Court favored Kline (MD) but supreme court reversed decision
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Consent - what court case ruled the obligation of a practitioner to disclose what a "reasonable person" would want to know about a tx before undergoing it
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Canterbury v. Spence (Wash DC) and Cobbs v. Grant (California)
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Consent - what two things are in use today
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Canterbury pt-oriented approach and Natanson professional standard
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5 components of informed consent
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1. type of procedure
2. risks associated with procedure 3. possible complications 4. expected benefits 5. alternatives |
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Where a check is indorsed "for deposit only" and stolen and thief cashes it at bank, is bank a holder?
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No. Bank blew it by not paying attention to the restriction.
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Informed consent - pt must ______ the information
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comprehend
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Informed consent - pt voluntarily gives consent without
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coercion or duress
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Informed consent - If you have evidence of a signed form, you have met the requirement of the law
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not true assumption
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Informed consent - can't exist unless what happens
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HCP has communicated the information clearly, concisely, and understandably
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Informed consent - communication is
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subjective
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Informed consent - what will pts claim in court
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lack of understanding
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Informed consent - what mitigates how much info should be disclosed
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the duty to disclose is measured by the amount of knowledge the pt needs
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What is the clinical term that refers to the ability to make rational and reasonably well informed decisions by a pt in their tx and/or life decisions
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capacity
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How is capacity determined
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While discussing an illness, workup, or procedure, the MD is simultaneously assessing level of comprehension. If there is a concern (to reasonable degree), often a second MD will be be consulted - this is often a psychiatrist (if available)
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What is the legal term that refers to the ability to make rational and reasonably well informed decisions by a pt in their tx and/or life decisions
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competency
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In criminal law, assault and battery are typically components of a
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single offense
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In tort law, assault and battery are
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separate
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Define assault
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an act which creates fear of an imminent battery
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Define battery
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willful or intentional touching of a person against that person's will by another person
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A person points a toy gun at someone from 50 feet away is considered
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assault
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If touching someone doesn't hurt them, can it still considered battery
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yes
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Spitting on someone is considered
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battery
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Who can sign informed consent
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18 y/o, emancipated minor - legally married, military, petitioned in court with legal documents, nonsurgical care if in law enforcement custody, legal guardians
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Informed consent - legal guardian must show
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proof
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Does pregnancy mean automatic emancipation
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Complicated answer - not automatic for everything
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If an incapacitated pt has not executed an advanced directive, or designated a surrogate to execute an advanced directive or if the alternative surrogate is no longer able to make decisions - what is the order
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1. spouse
2. adult child 3. parents 4. adult sibling 5. adult relative/close friend |
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What type of consent is used after reasonable attempts to contact family have been made
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implied consent
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What type of consent if the tx is considered lift threatening
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implied consent
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Who signs for implied consent
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two people - usually surgeon and CRNA - depends of hospital policy (must document attempts made to contact family)
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Does surgery terminate advanced directives
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at many institutions, yes there is temporary cessation of DNR orders
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DNR orders - what is most important
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discussion with family of implications of general anesthesia (return intubated, etc) and DOCUMENT this
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