Topic 1: Documentation and Regulatory Compliance
Based on the information you have learned in the course so far and the readings, analyze the advantages and disadvantages of charting by exception when faced with a malpractice lawsuit. Discuss how you would correct mistakes in a medical chart and the formatting of your documentation when witnessing an adverse patient occurrence (APO). What APOs have to be reported in your state? How would charting corrections be perceived in a court of law? What are the implications for handling of forensic issues?
Topic 2: Impaired Nurses
Assume that you have knowledge that the nurse working with you on your unit has been illegally using drugs. What are your obligations to disclose this? What are your obligations to the institution you work for? Are there any places you could refer the nurse to? What are the implications for this nurse’s license? Are there any potential risks to your license? If so, what?
Activities
Textbook Readings
Readings
Essentials of Nursing Law and Ethics
Expert Solution Preview
Introduction:
As a medical professor responsible for creating assignments and evaluating student performance, it is essential to assess the knowledge and critical thinking skills of the students. In this assignment, two different topics are given, and both topics require analytical thinking and comprehension of the medical law. Therefore, it is essential to provide comprehensive answers backed by credible sources.
Topic 1: Documentation and Regulatory Compliance
Charting by exception is a documentation method that records only abnormal findings or exceptions to the norm, essentially, it documents what needs to be done and what is not done (Wulff & Shearer, 2017). One of the advantages of charting by exception is that it saves time, which can be utilized for direct patient care. However, the major disadvantage of charting by exception is that it leaves out important details and observations that could be relevant in clinical assessments, diagnosis, and treatment.
When correcting mistakes in a medical chart, the corrections should be made using the designated correction method. The original content should remain legible, and the update should be recorded with the current date, time, and name of the person making the change. If an APO is witnessed, the documentation should include the patient’s name, the date and time of the occurrence, and a detailed description of the event. The state-specific reporting requirements for an APO vary, but typically, events that cause significant harm or death should be reported. Charting corrections would be perceived in a court of law as evidence of an attempt to correct an error or omission, which could be crucial in defending against a malpractice lawsuit.
Forensic issues like liability, negligence, or intentional harm in healthcare can lead to civil or criminal charges. Law enforcement or authorities may investigate such issues, and the documentation would be part of the official record. Therefore, it is essential to ensure that the charting and reporting are accurate, truthful, and comply with regulatory requirements.
Topic 2: Impaired Nurses
As a healthcare professional, it is my ethical duty to report suspicions of drug use by a co-worker to protect patient safety and uphold the integrity of the profession (American Nurses Association, 2015). Therefore, I have an obligation to report the nurse’s suspected drug use to the appropriate authority or supervisor, such as the head nurse or human resources.
As an employee of the institution, I have an obligation to comply with the institution’s policies and regulations regarding incidents of illegal drug use and impairment. The institution should have a reporting system in place, and the disclosure should follow the chain of command and adhere to the institution’s procedures.
The nurse could be referred to an Employee Assistance Program, where she could receive counseling and support to address the drug use disorder. The nurse’s license could be suspended or revoked if found guilty of drug use, and the implications would depend on the state’s nursing board regulations.
As a nurse reporting suspected drug use, there could be potential risks to my license if found to be false or reported maliciously. Therefore, it is crucial to report suspicions based on credible evidence and only after careful consideration of the nurse’s well-being and patient safety.
In conclusion, healthcare professionals have ethical, legal, and regulatory responsibilities that must be upheld to ensure patient safety and promote the integrity of the healthcare profession. This assignment provides an opportunity for medical students to analyze and apply the concepts learned in the course material.
References:
American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, Maryland: Nursesbooks.org.
Wulff, K., & Shearer, R. (2017). Nursing documentation: A nursing process approach. Philadelphia, PA: F.A. Davis Company.
