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Stay out of court with proper documentation

doi: 10.1097/01.NURSE.0000396159.83608.84
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INSTRUCTIONS Stay out of court with proper documentation


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  • Registration deadline is April 30, 2013.
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Stay out of court with proper documentation

GENERAL PURPOSE: To provide nurses with guidelines for avoiding legal problems by documenting patient care completely and accurately. LEARNING OBJECTIVES: After reading the preceding article and taking this test, you should be able to: 1. Define legal terms and concepts related to professional negligence lawsuits. 2. Discuss elements of good nursing practice that help prevent legal problems. 3. Identify common errors in documentation that open nurses to legal liability.

1. Failure to provide the standard of care resulting in injury to the patient is

a. damages.

b. professional negligence.

c. breach of standard of care.

d. breach of duty.

2. When you accept care of a patient under your scope of practice, which legal element exists?

a. duty to the patient

b. duty to the employer

c. element of reason and logic

d. element of justice

3. In a professional negligence case, the plaintiff must prove that the care provided by a nurse was

a. reasonable.

b. standard.

c. prudent.

d. substandard.

4. Professional negligence requires that the patient be

a. under the care of an RN.

b. under a physician's care.

c. injured.

d. hospitalized.

5. Professional negligence requires that the breach of a standard of care

a. contributed to the injury.

b. directly caused the injury.

c. was based on national standards.

d. was based on hospital standards.

6. All of the following are documentation "red flags"except

a. erased entries.

b. late entries.

c. incomplete entries.

d. sequentially timed entries.

7. Assessment documentation should

a. be objective.

b. be subjective.

c. use labels to describe behavior.

d. paraphrase the patient's words.

8. Documentation of patient assessments or treatments should be done

a. at the time of care.

b. within 1 hour of care.

c. within 4 hours of care.

d. at the end of the shift.

9. Which of the following can help eliminate gaps in the medical record?

a. pretimed areas for notes

b. flowcharts

c. checklists

d. EMRs

10. Liability exposure can occur, even when none is warranted, if you deviate from your facility's policies on

a. education.

b. patient assignments.

c. documentation.

d. shift report.

11. When a late entry is made several days after it should have been made, you should

a. include a rationale for the delay.

b. don't mention why it's late.

c. notify risk management.

d. notify nursing administration.

12. After an adverse event, what informationshouldn'tbe documented in the patient's medical record?

a. date and time of the event

b. assessment of the patient's condition

c. medical interventions

d. notation that an event report was completed

13. In general, event reports are sent from the nursing care unit to

a. attorneys.

b. the director of nursing.

c. risk management.

d. the medical director.

14. In Scenario 1, the nurse might have prevented the patient's injury by

a. delegating care carefully.

b. following standards of care.

c. documenting legibly.

d. educating the family.

15. Which issue is described in Scenario 2?

a. administering a high-risk drug

b. acting against hospital policy

c. failing to document care

d. failing to communicate

16. One of the most common causes of negligence lawsuits involving nurses is allegations of

a. assessment errors.

b. medication errors.

c. communication delays.

d. inadequate monitoring.

17. Scenario 3 demonstrates the importance of documenting

a. care provided.

b. conversations.

c. assessments.

d. diagnostic test results.

18. The most important factor in avoiding legal problems is

a. documenting care properly.

b. having medical malpractice insurance.

c. requiring supervision.

d. avoiding unsafe patient assignments.



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