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Advance health care directives a variety of legal and lay documents that allow persons to specify aspects of care they wish to receive should they become unable to make or communicate their preferences Answer (legal) a written response made by the defendant Assault an attempt or threat to touch another person unjustifably Autopsy an examination of the body after death to determine the cause of death and to learn more about a disease process Battery (legal) the willful or negligent touching of a person (or the person's clothes or even something the person is carrying), which may or may not cause harm Breach of duty a standard of care that is expected in the specific situation but that the nurse did not observe, this is the failure to act as a reasonable, prudent nurse under the circumstances Burden of proof the duty of providing an assertion Causation a fact that most be proven that the harm occurred as a direct result of the nurse's failure to follow the standard of care and the nurse could have (or should have) known that the failure to follow the standard of care could result in harm Civil actions deals with the relationship between individuals in society Civil law the body of law that deals with relationships among private individuals; also known as private law Common law the body of principles that evolves from court decisions Complaint (legal) a document that is filed by a plaintiff Contract a written or verbal agreement between two or more people to do or not do some lawful act Contract law the enforcement of agreements among private individuals or the payment of compensation for failure to fufill the agreement Contractual obligations duty of care established by the prescene of an expressed or implied contract Contractual relationships vary among practice settings: may be as an independent or employer-employee relationship Coroner a physican who is authorized by the county or other government agency to determine causes of deaths under unusual circumstances Credentialing the process of determing and maintaining competence in practice; includes licensure, registration, certification and accreditation Crime an act committed in violation of public (criminal) law and punishable by a fine and/or imprisonment Criminal actions deal with disputes between an individual and the society as a whole Criminal law deals with actions against the safety and welfare of the public Damages if malpractice caused the injury, the nurse is held liable ofr damages that may be compensated Decision (legal) outcome made by a judge Defamation (legal) a communication that is false, or made with careless disregard for the truth, and results in injury to the reputation of another, libel and slander Defendants (legal) person against whom a plaintiff files a complaint Delegation transference of responsibility and authority for an activity to a competent individual Discovery (legal) pretrial activities to gain all of that facts of a situation Do not resuscitate (DNR) ... Duty the nurse must have (or should have had) a relationship with the client that involves providing care and following an acceptable standard of care Euthanasia the act of painlessly putting to death persons suffering from incurable or distressing disease Expert Witness one who has special training, experience, or skill in a relevant area and is allowed by the court to offer an opinion on some issue within that area of expertise Express consent an oral or written agreement False imprisonment the unlawful restraint or detention of another person against his or her wishes Felony a crime of serious nature, such as murder, punishable by a term in prison Foreseeability a link that must exist between the nurse's act and the injury suffered Gross negligence involves extreme lack of knowledge, skill or decision making that the person clearly should have known would put others at risk for harm Harm (injury) the client or plaintiff must demonstrate that some type of harm of injury (physical, financial, or emotional) as a result of the breach of duty owed the client; the plaintiff will be asked to document physical injury, medical costs, loss of wages, "pain and suffering" and any other damages Health care proxy a legal statement that appoints a proxy to make medical decisions for the purpose of achieving a higher level of health and well-being, also referred to as a durable power of attorney for health care Impaired nurse a nurse whose practice has deteriorated because of chemical abuse Implied consent consent that is assumed in an emergency when consent cannot be obtained from the client or relative Implied contract a contract that has not been explicitly agreed to by the parties but that the law nevertheless considers to exist Informed consent a client's agreement to accept a course of treatment or a procedure after receiving complete information, including the risks of treatment and facts relating to it, from the health care provider injury same as harm inquest a legal inquiry into the cause or manner of a death interstate compact an agreement between two or more states invasion of privacy a direct wrong of a personal nature, it injures the feelings of the person and does not take into account the effect of revealed information on the standing of the person in the community law a rule made by humans that regulated social conduct in a formally prescribed and binding manner liability the quality or state of being legally responsible for one's obligations and action and to make financial restitution for wrongful acts Libel defamation by means of print, writing, or pictures License a legal permit granted to individuals to engage int he practice of a profession and to use a particular title Litigation the action of a law suit Living will a document that states medical treatment(s) the client chooses to omit or refuse in the event that the client is unable to make those decisions Malpractice the negligent acts of persons engaged in professions or occupations in which highly technical or professional skills are employed Mandated reporters a role of the nurse in which he or she identifies and assesses cases of violence against others, and in every case the situation must be reported to the proper authorities Manslaughter second-degree murder Medical examiner a physician who usually has advanced education in pathology or forensic medicine who determines causes of death Misdemeanor a legal offense usually punishable by a fine or a short term jail sentence or both Mutual recognition model a regulatory model developed by the National Council of State Boards of Nursing (NCSBN) which allows for multistate licensure Negligence failure to behave in a reasonable and prudent manner, an unintentional tort Plaintiff a person claiming infringement of legal rights by one or more persons Postmortem examination see autopsy Private law (civil) the body of law that deals with relationships between private individuals Public law refers to the body of law that deals with relationships between individuals and the government and governmental agencies Res ipsa loquitur "the thing that speaks for itself", a legal doctrine that relates to negligence in which the harm cannot be traced to a specific health care provider or standard but does not normally occur unless there has been a negligent act Respondeat superior a legal term meaning "let the master answer", the employer assumes responsibility for the conduct of the employee and can also be held responsible for malpractice by the employee, related to negligence Responsibility the specific accountability or liability associated with the performance of duties of a particular role Right (legal) a priviledge or fundamental power to which an individual is entitiled unless it is revoked by law or given up voluntarily Slander defamation by the spoken word, stating unpriviledged (not legally protected) or false words by which a reputation is damaged Standard of care the skills and learning commonly possessed by members of a profession Statutory laws a law enacted by any legislative body Strike an organized work stoppage by a group of employees to express a grievance, enforce a demand for chagnes in condition of employment, or solve a dispute with management Tort a civil wrong committed against a person or a person's property Tort Law law that defines and enforces duties and rights among private individuals that are not based on contractual agreements Trial the period during which all relevant facts are presented to a jury or judge Unprofessional conduct one of the grounds for action against against the nurse's license, includes incompetence or gross negligence, conviction of practicing without a license, falsification of client records, and illegally obtaining, using or possessing controlled substances Verdict the outcome made by a jury Knowledge of laws that regulate and affect nursing practice is needed for two reasons? 1. to ensure that the nurse's decisions and actions are consistent with current legal principles 2. To protect the nurse from liability What does the nurse practice act define? the scope of nursing Besides the nurse practice act how do state legally control nursing? through licensing requirements How does credentialing maintain the standard of nursing? accountability for the education preparation of its memeber, includes licensure, certification and accrediation What are the two classification of standard of care? internal and external standards What does internal classification consist of? the nurse's job description, education and expertise as well as individual institutional policies and procedures What does external classification consist of? nurse practice acts, professional organizations, nursing speciality-practice organizations, federal organizations and federal guidelines What makes a contract expressed? when the two parties discuss and agree, orally or in writing to terms and conditions during the creation of the contract What four features does a lawful contract require? 1. promise or agreement between two or more persons for the performance of an action or restraint from certain actions 2. Mutual understanding of the terms and meaning of the contract by all 3. A lawful purpose (the activity must be legal) 4. Compensation in the form of something of value-in most cases, compensation is monetary. A form that a client signs for consent is also a? record of the informed consent, not the informed consent itself Informed consent has three major elements? 1. the consent must be give voluntarily 2. the consent must be given by a client or individual with the capacity and competence to understand 3. the client or individual must be given enough information to be the ultimate decision maker Literacy an indiviuals's ability to read, write and speak in English and compute and solve problems at levels of proficiency necessary to function on the job and in society, to acieve one's goal's and develop one's knowledge and potential Low literacy a limited ability to do what is defined as literacy illiteracy being unable to read or write Health literacy the degree to which individuals have the capacity to obtain, process and understand basic health information and servides needes to make appropriate health decisions What groups cannot provide consent? minors, adult with mental capacity of a child and who has an appointed guardian, persons who are unconscious or injured in a way that they are unable to give consent, people with mental illnesses who have been judged by professionals to be incompetent Is the nurse responsible for explaining the procedure? no In regards to the consent form what is the nurse responsible for? witnessing the signature and confirming 1. the client gave consent voluntarily 2. the signature is authentic 3. the client appears competent to give consent What is an important aspect of conformed consent? documentation What type of law is nursing liability usually involved with? tort How are torts classified? intentional or unintentional What are the categories of negligence that result in malpractice lawsuits? failure to follow standards of care failure to use equipment in a responsible manner failure to communicate failure to document failure to assess and monitor failure to act as a client advocate What six elements must be present for a case of nursing malpractice to be proven? duty, breech of duty, foreseeability, causation, harm or injury, damages define duty the nurse must have a relationship with client that involves providing care and following an acceptable standard of care. define breech of duty something was done that should not have been done or nothing was done when it should have been done, standard of care define foreseeability a link must exist between the nurse's act and the injury suffered define causation must be proved that the harm occured as a direct result of the nurse's failure to follow the standard of care and that the nurse should of know this define harm or injury the client must demonstrate some type of harm or injury as a result of the breach of duty owed the client define damages if malpractice caused the injury the nurse is held liable for damages that may be compensated What is the statue of limitation for a client to bring a lawsuit? 1-2 years from the time they knew of the injury In what situation are negligent errors most likely to occur? medication errors To be a client advocate, what must you know about medications being administered? why the client is receiving the medication, the dosage range, possible adverse effects, toxicity levels and contraindications A nurse who threatens a client with an injections after the client refuses to take the medication orally would be committing? assualt If the client followed through with ther threat and gave the client the injection what would she be committing? battery, when there is no consent What does a client sign when he insists on leaving against the nurses suggestions? AMA (against medical advice) What are the four types of invasion a client must be protected against? use of the client's name or likeness for profit, without consent, unreasonable intrustion, public disclosure of private facts, putting a person in a false light define use of the client's name or likeness for profit, without consent refers to the use of identifiable photographs or names such as advertising for the health care agency or provider without the client's permission define unreasonable intrusion involves observation of a client care (such as by nursing students) or taking of photographs for any purpose without the client's consent define public disclosure of facts private information is give to others who have no legitimate need for that information define putting a person in a false light this type of invasion involves publishing information that is normally considered offensive but which is not true The Health Insurance Portability and Accountability Act of 1996 (HIPAA) the first nationwide legislation to protect privacy for health information Standards for Privacy of Individually Identifiable Health Information 2003 also known as the privacy rule What four areas does HIPPA include 1. electronic transfer of information 2. standardized numbers 3. security rule 4. privacy rule Define electronic transfer of information (HIPPA) HIPAA implements a national unifrom standard to simplify transactions (electronic format for claims) Define standardized numbers identifies providers, employers and health plans Define security rule provides uniform level of protection of all health information, Define privacy rule sets standards defining appropriate disclosure of protected health information, gives clients new rights to understand and control how their health information is used Ominbus Budget Reconciliation Act of 1993 (OBRA 93) created the pediatric vaccine distribution program, certain groups of children vaccinated for no charge, 18 years or younger, eligble for medicaid, unisured.. Omnibus Budget Reconcillation Act (OBRA) 1990 ensuring quality care in skilled nursing facilities How can nurses improve their working conditions? collectively bargening What does the nurse practice act define? legally defines and describes the scope of nursing practice that the law seeks to regulate Informed consent implies 1. consent was given voluntarily 2. client was of age and had the capacity and competency to understand 3. the client was given enough information to make an informed decision Americans with Disabilities Act of 1990 prohibits? discrimination on the basis of disability in employment, public services and public accommodations What is an unintentional tort? a nurse is liable for damages, did not meet critera and nurse failed to carry out duty to the client What is an intentional tort? assault, battery, false imprisonment, invasion of privacy, and defamation What does the Good Samaritan act do? protects health professionals from claims of malpractice when they offer assistance at the scene of an emergency, provided that there is no willful wrongdoing or gross departure from normal standards of care What is a nurse's first responsibility when a client is accidentally injured or involved in an unusual situation? take steps to protect the client and then to notify appropriate agency personnel A primary care provider's orders indicate that a surgical consent form needs to be signed. Since the nurse was not present when the primary care provider discussed the surgical procedure, what should the nurse say to the client. What were you told about the procedure you are going to have. Although the client refused the procedure, the nurse insisted and inserted a neogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following? battery A nurse discovers that a primary care provider has prescribed an unusually large dosage of a medication. What action should be taken? notify the prescriber A primary care provider prescribes one tablet, but the nurse accidently administers two. After notifying the primary care provider, the nurse monitors the client carefully for untoward effects of which there are none. Is the client likely to be successful in suing the nurse for malpractice. No, the client was not harmed A nursing student is employed and working as an unlicensed assistive personnel (UAP) on a busy surgical unit. The nurses know that the UAP is enrolled in a nursing program and will be graduating soon. A nurse asks the UAP if he has performed a urinary catheterization on clients while in the nursing program. When the UAP says Yes the nurse asks him to help her out by doing a urinary catheterization on a postsurgical clients. What is the best response by the UAP? I can't do it, is there something else I can help you with The primary care provider wrote a do-not resuscitate (DNR) order. The nurse recognizes that which applies in the planning of nursing care for this client? The nurses will continue to implement all treatments focused on comfort and symptom management. The nurses parner/spouse undergoes exploratory surgery at the hospital where the nurse is employed. Which practice is most appropriate? Access to the chart requires a signed release form Following a motor vehicle crash, a nurse stops and offers assistance. Which of the following action is/are most appropriate? The nurse needs to knwo the Good Samaritan Act for the state The nurse is not held liable unless there is gross negligence The nurse offers to help but cannot insist on helping The nurse notices that a colleague's behaviors have changed during the past month. which behaviors could indicate signs of impairments? Is increasingly absent from the nursing unit during the shift forgets to sign out for administration of controlled substances offers to administer pm opiods for other nurses clients What nursing actions could result in malpractice? Forgets to complete the assessment of a client Does not follow up on client's complaints