Allegality And Ethics Of Patient Documentation Research Paper

Running head: LEGALITY AND ETHICS OF PATIENT DOCUMENTATION 1Legality and Ethics of Patient Documentation Matraca HillOzarks Technical Community College

LEGALITY AND ETHICS OF PATIENT DOCUMENTATION2Legality and ethics of patient documentationNurses often hear the saying: “if it is not charted, then it was not done” from day one of nursing school. All states have what is called a Nurse Practice Act, which is governed by the state’s legislature and these laws protect the safety of nursing practice (Duclos-Miller,2016). By having this act it gives healthcare workers rules and regulation for their licenses and workplaces. Each state has a state board of nursing to make the laws effective and provide enforcement (Duclos-Miller,2016). Nurses must

If the nurse provides false information it would mean life or death for a patient, especially a pediatric patient. We will further discuss false documenting later. The ANA also states that the nurses should be proficient in the software that is being used for patient documentation. The nurse should be aware and use caution when using copy/paste functions within an electronic health record (EHR), as this can be considered false assessments. If using paper records, the nurse should never leave blank spaces to cart at a later time (Curtin, 2014). Doing so could allow someone else to chart something that could get one in trouble. Healthcare workers also should make sure they are always protecting patient privacy. Leaving charts open and sharing info is a breach of privacy and can result in large fines and even jail time if severe. The American Nurses Association offers great resources for the practicing nurses. Another resource is the National Council of State Boards of Nursing (NCSBN).Ethics of documentationWhen you hear the word ethics, what comes to mind? Many think of a code that you should follow with the activity you are participating in. There are rights and wrongs of documentation. We should always document accurate and pertinent information. We should never document falsely or document in such a manner that it would

No matter how the nurse feels, the care and documentation are ALWAYS patient-centered. The EHR is likely to have preset templates and algorithms that make the nurse click boxes and decisions. The nurse needs to know when it is appropriate to use a free text or write a narrative to allow for adequate and legal documentation. Another consideration would be if the nurse notices something is not accurate in the chart. The appropriate ethical action would be to contact the doctor or needed person to correct the error. If the nurse did not take action and then the patient sued, the nurse would also be sued. This is because the EHR tracks every movement the employee makes while using the system. EHR systems can actually time how long you are in each window or even how long it takes to close out an alert. Let’s talk about the ethics behind falsifying documentation. This can be morally distressing if one has lied. How about losing sleep or simply no longer caring about your job or the safety of your patients? Ethically every nurse knows what the right actions are. We need to remember the patient has the right to choose what happens in their care, whether we feel it is appropriate or not. Part of being a great competent practicing nurse is being alert for unethical actions by team members. What should one do if witnessing a co-worker falsifying documentation? Contact the manager or