HCS 101 INTRODUCTION TO HEALTHCARE 1

L. L. BINAY-AN
I. INTRODUCTION TO HEALTHCARE
Health
Health is a state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity (WHO)
Healthcare
The prevention, treatment, and management of illness and the preservation of
mental and physical well-being through the services offered by the medical and
allied health professions.
Healthcare Delivery System
The totality of all polices, infrastructures, facilities, equipment, products, human
resource services that address the health needs, problems and concerns of all
people.

a. General Types of Health Services

1. Health Promotion
services designed to reduce the risk of illness, maintain maximal function,
promote good health habits
2. Illness prevention
services designed to reduce the risk factors in an effort to avoid primary,
secondary or tertialry health prevention
3. Diagnosis and Treatment
most commonly used service, sought once a person feels ill
*Diagnosis- the art or act of identifying a disease from its signs and symptoms
*Treatment- the action or manner of treating a patient medically or surgically
4. Rehabilitation/ Restorative Care
services designed for restoration of a person to the highest of physical and
physiological functioning, maximizing abilities and independence

b. Levels of Healthcare Facilities and Services

1. Primary Level
Healthcare services rendered at this level are to individuals in fair heath and to
clients with diseases in early symptomatic stages
Agencies on this level are the point qof entry to the healthcare system
Settings:

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o Health center in the community (Rural Health Centers, Barangay Health
Center)
o Schools
o Private clinics
2. Secondary Level
health care services provided by medical specialists and other health
professionals who generally do not have first contact with patients, for
example, cardiologists, urologists and dermatologists.
hospital care
3. Tertiary Care
specialized consultative health care, usually for inpatients and on referral from
a primary or secondary health professional, in a facility that has personnel and
facilities for advanced medical investigation and treatment, such as a tertiary
referral hospital
examples of tertiary care services are cancer management, neurosurgery,
cardiac surgery, plastic surgery, treatment for severe burns, advanced
neonatology services, palliative, and other complex medical and surgical
interventions

c. Types of Healthcare Organizations

1. Hospital- provides care for people with acute medical or surgical conditions
2. Subacute Care Unit- provides care for people who have been discharged from the
hospital but still need care from a skilled health care professional
Ex. Skilled nursing Unit, Skilled Nursing Facility
3. Long Term Care Facility- provides care for people who are unable to take care for
themselves at home but do not need to be hospitalized
Ex. Nursing Homes., Home for the aged
4. Home Health Care Agency- provides skilled care in a persons home
5. Hospice Organization-provides care for the people who are dying and their families
-provides palliative care
-focuses on relieving pain and spiritual support
*Palliative care -an area of healthcare that focuses on relieving and preventing the
suffering of patients.

Patients, Residents, Clients
Patient- person being cared for in the hospital
Resident-person being cared for in a long term care facility

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d. Classification of Patients

1. Surgical Patients- have conditions treated by surgery
2. Medical Patients- have conditions treated by methods other than surgery
3. Obstetric Patients-those who are pregnant or have just given birth
4. Pediatric Patients- children and adolescents
5. Geriatric Patients- adults more than 65 years of age
6. Rehabilitation Patients- receiving therapies to restore their higher level of functioning
7. Sub-acute or Extended-care Patients- do not need the total care provided by a
hospital but needs intravenous medications, physical therapies, or other treatment
that cannot be provided by untrained caretakers
8. Intensive Care Patients- patients who are cortically ill and require highly skilled
monitoring and care

e. The Nursing Assistant as a Member of the Healthcare Team

As a member of the Nursing Department, the nurse Assistant plays an important role
in resident care. The nurse Assistant spends more time in direct contact with the
resident than any other member of the health care team.
The Healthcare Team
1. Physicians
2. Nurses
3. Nursing Assistants
4. Pharmacists
5. Respiratory Therapists
6. Physical Therapists
7. Medical Technicians
8. Nutritionists
9. General Services

The Nurse Assistant Works in a Variety of Setting
Hospitals
Long term care facilities
Rehabilitation centers
Clinics
Hospices
Psychiatric facilities
Home care

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f. Functions of Nurse Assistant

1. Help residents with personal needs or assist patients/ residents in the Activities of
Daily Living (ADLs)
Hygiene
Safety
Nutrition
Exercise
Elimination
Mobility
Communication
Socialization activities
Comfort measures
Restorative procedures

2. Assist with resident care responsibilities:
Collecting specimens
Measuring and recording vital signs
Transporting residents
Environmental cleanliness
Cleaning and care of equipment
Standard precautions
Fire drills and disaster drills
Answering call signals
Observation of resident response to care
Measuring and recording height/weight
Intake and output

g. Legal Limitations Of The Nurse Assistant

1. Giving medications
2. Receiving verbal orders
3. Diagnosing illness and prescribing medications
4. Supervising other nursing assistant
5. Performing procedure that require sterile techniques

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6. Inserting of removing tubes from a persons body
7. Procedures the nurse Assistants scope of practice as defined by the state law

f. Obligations of the Nurse Assistant as a Member of the Health
Care Team

1. Resident Care Conferences
Assist to develop/revise care plans
Share care suggestions
Report observations

2. Planning Work Assignment

Work Assignments
o Made by a licensed nurse
o Based on needs of residents and availability of staff
o Allows staff to work as team
o Includes being cooperative and helping others when asked
o Includes never ignoring a resident that needs help, is uncomfortable or in danger

3. Establishing Priorities for Care

1. Activities of daily living
Meeting hygiene needs
Positioning and providing for exercise
Maintaining proper nutrition
Providing for elimination of wastes

2. Examples of special procedures
Taking vital signs
Measuring urine

3. Support services
Providing drinking water
Delivering and picking up meal trays

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Providing clean linen and making beds
Cleaning and caring for equipment

II. ETHICO-LEGAL ASPECTS IN NURSING CARE

I. THE RIGHTS OF PATIENTS

The following rights of the patient shall be respected by all those involved in his care:

1. Right to Good Quality Health Care and Humane Treatment
a. Every person has a right to good quality health care without any discrimination and within
the limits of the resources available for health and medical care.

b. In the course of such care, his human dignity, culture, convictions and integrity shall be
respected.

c. If the patient has to wait for care, he shall be informed by the health professionals of the
reason for the delay.

d. The patient shall always be treated in accordance with his best interests. The treatment
applied shall be in accordance with generally accepted medical principles.

e. The patient has the right of continuity of health care.

f. An emergency patient who is immediate threat of dying or losing life or limb shall be
extended immediate medical care and treatment without any pecuniary consideration until
the emergency situation is over.

2. Right to Dignity
a. The patient's dignity, culture and value shall be respected at all times in medical care and
teaching.

b. Terminal ill patients are entitled to humane terminal care to make dying as dignified and
comfortable as possible.



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3. Right to Be Informed of His Rights and Obligations as a Patient
Every person has the right to be informed of his rights and obligations as a patient.

4. Right to Choose His Physician
a. The patient is free to avail of the services of a physician or health institution of his choice
except when he chooses to be confined in a service ward.
b. The patient has the right to seek a second opinion.
c.The patient has the right to change his physician or other health care provider.

5. Right to Informed Consent
a. The patient has the right to self-determination, to make free decisions regarding himself.
The physician shall inform the patient of the consequences of his decisions.

b. Patient who is mentally competent and of legal age or in his incapacity or age of minority
his legal representative, has a right to a clear explanation, in layperson's terms, of all
proposed or contemplated procedures whether diagnostic or therapeutic, including the
identity and professional circumstances of the person or persons who will perform the said
procedure or procedure
1. If the patient is unconscious or unable to express his will, informed consent must be
obtained whenever possible from a legal representative.
2. When medical intervention is urgently needed, consent of the patient may be
presumed.
3. Physicians should always try to save the life of a patient unconscious due to a suicide
attempt.
c. The unconscious patient
d.The legally incompetent patient
1) If a patient is a minor or legally incompetent the consent of a legally representative
is required. Nevertheless the patient must be involved in the decision making to the
fullest extent allowed by his mental capacity.
A patient, who is eighteen years of age and above, shall be considered, for purposes
of this declaration, to be of legal age.
2) If the legally incompetent patient can make rational decisions, his decisions must
be respected, and he has the right to forbid the disclosure of information to his
legally representative.

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3) If the patient's legal representative, forbids treatment but, in the opinion of the
physician contrary to the patient's best interest, the physician may challenge this
decision in court. In case of emergency, the physician will act in the patient's best
interest.
e. In case of emergency, when there is no one who can give consent in his behalf, the
physician can perform any emergency diagnostic or treatment procedure in the best
interests of the patient

6. Right to REFUSE DIAGNOSTIC AND MEDICAL TREATMENT

a.The patient has the right to refuse diagnostic and medical treatment procedures, provided
that the following conditions are satisfied:
1. He is of age twenty one and above, and mentally competent;
2. He is informed of the medical consequences of his refusal;
3. He releases those involved in his care from any
4. obligation relative to the consequences of his decision; and
5. His refusal will not jeopardize public health and safety.
b.An adult with a sound mind may execute an advance directive for physicians not to put
him on prolonged life support if, in the future, his condition is such that there is little or no
hope of reasonable recovery and the physician

7. Right to Refuse Participation in Medical Research
The patient has the right to be advised of plans to involve him in medical research that may
affect the care or treatment of his condition. The proposed research shall be performed only
upon the written informed consent of the patient.

8. Right to Religious Belief and Assistance
The patient has the right to receive spiritual and moral comfort including the help of a
minister of his chosen religion.

9. Right to Privacy and Confidentiality
The patient has the right to privacy and protection from unwarranted publicity. This right to
privacy shall include the patient's right not to be subjected to exposure, private or public,
either by photography, publications, video-taping, discussion, medical teaching or by any
other means that would otherwise tend to reveal his person and identity and the

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L. L. BINAY-AN
circumstances under which he was, he is, or he will be, under medical or surgical care or
treatment.

a. All identifiable information about a patient's health status, medical condition, diagnosis,
prognosis and treatment and all other information of a personal kind, must be kept
confidential, even after death. Except, in cases when descendants may have a right of
access to information that would inform them of their health risks.

b. All identifiable patient data must be protected. The protection of the data must be
appropriate as to the manner of its storage. Human substance from which identifiable data
can be derived must be likewise protected.

c. Confidential information can be disclosed in the following cases:
1. when his mental or physical condition is in controversy in a court litigation and the
court in its discretion orders him to submit to physical or mental
2. examination by a physician;
3. when the public health and safety so demand;
4. when the patient or, in his incapacity, his legal
5. representative expressly gives the consent;
6. when his medical or surgical condition, without revealing
7. his identity, is discussed in a medical or scientific forum
8. for expert discussion for his benefit or for the
9. advancement of science and medicine.
10. when it is otherwise required by law.
10. Right to Disclosure of, and Access to Information

a. In the course of his treatment and hospital care, the patient has the right to be informed
of the result of the evaluation of the nature and extent of his disease. Any other additional
or further contemplated medical treatment and surgical procedure or procedures.

b. Disclosure of information maybe withheld if the information to the patient will cause
mental suffering or further impair his health. Such disclosure may be withheld or deferred at
some future opportune time upon due consultation with the patient's immediate family.


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c. Information must be given in a way appropriate to the local culture and in waiver the
patient can understand.

d. The patient has the right not to be informed on his explicit request, unless required for
the protection of another person's life.

e. The patient has the right to choose who, if anyone, should be informed on his behalf.
f. The patient has the right to examine and be given an itemized bill of the hospital and
medical services rendered.

g. The patient or his legal representative, has the right to be informed by the physician or
his delegate of his continuing health care requirements following discharge, including
instructions about home medications, diet, physical activity and all other pertinent
information.

11. Right to Correspondence and to Receive Visitors
The patient has the right to communicate with relatives and other persons and to receive
visitors subject to reasonable limits prescribed by the rules and regulations of the health
care institution.

12. Right to Medical Records
The health care institution and the physician shall ensure and safeguard the integrity and
authenticity of the medical records.

a. Upon the request of patient, the physician shall issue a medical certificate, a clinical
abstract to the patient upon discharge from the institution. Any relevant document that the
patient may require for insurance claims shall also be made available to him within a
reasonable period of time.

b. He has the right to view the contents of his medical records with the attending physician
explaining contents thereof and at his expense.
c. The patient may obtain from the health care institution a reproduction of his medical
record at his expense.

13. Right to Health Education

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Every person has the right to health education that will assist him in making informed
choices about personal health and about the available health services. The education should
include information about healthy lifestyles and about methods of prevention and early
detection of illnesses. The personal responsibility of everybody for his own health should be
stressed. Physicians should have an obligation to participate actively in educational efforts.

14. Right to Express Grievances
The patient has the right to express only valid complaints and grievances about the care
and services received. Patients may express their complaints and grievances with the Ethics
Committee of the Philippine Medical Association through its component societies which
shall afford all parties concerned with the opportunity to settle amicably all grievances.


II. UNDERSTANDING THE CONCEPT OF ETHICS

A. ETHICS VERSUS MORALITY

ETHICS
Derived from the Greek word ethos, meaning custom or character
Defined as the branch of philosophy dealing with standards of conduct and moral
judgment
Refers to a method of inquiry that assists people to understand the morality of human
behavior (i.e. it is the study of morality)
Refers to the practices or beliefs of a certain group (i.e. Nursing ethics, Physicians'
ethics)
Ethics is concerned what ought to be, what is right, or wrong, good or bad. It is the
base on moral reasoning and reflects set of values
It is a formal reasoning process used to determine right conduct. It is professionally
and publicly stated
MORALS

Principles and rules of right conduct
It isprivate or personal
Society & culture play important role in the development of ones morals
B. COMMON ETHICAL THEORIES

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Ethical theories may be compared to lenses that help us to view an ethical problem.

1. Deontology
2. Teleology
3. Intuitionism
4. The ethics of caring

1. Deontology (Duty or rule-Based theory)
This theory proposes that the rightness or wrongness of an action depends on the
nature of the act rather than its consequences.

2. Teleology (utilitarian or end based theory)
This theory looks to the consequences of an action in judging whether that action is
right or wrong.

3. Intuitions
The notion that people inherently know what is right or wrong; determining what is
not a matter of rational thought or learning. For example, nurse inherently known it
is wrong to strike a client, this does not need to be taught or reasoned out.

4. The ethics of caring (case based theory)
Unlike the preceding theories which are based on the concept of fairness (justice) an
ethical caring is based on relationships.
It stresses courage, generosity, commitment, and responsibility. Caring is a force for
protecting and enhancing client dignity.


C. ETHICAL PRINCIPLES

Principles are basic ideas that are starting points for understanding and working
through a problem. Ethical principles presuppose that nurses should respect the value
and uniqueness of persons and consider others to be worthy of high regard.

1. Autonomy


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Autonomy is the promotion of independent choice, self-determination and freedom
of action.
Autonomy means independence and ability to be self-directed in healthcare.
Autonomy is the basis for the client's right to self-determination.
It means clients are entitled to make decision about what will happen to their body.

Informed consent: is a process by which patients areinformed of the possible outcomes,
alternatives and risks of treatments and are required to give their consent freely. It assures
the legal protection of a patients right to personal autonomy in regard to specific
treatmentsand procedures.
Paternalism: Restricting others autonomy to protectfrom perceived or anticipated
harm.Paternalism is appropriate when the patient is judged to be incompetent or to have
diminished decision-making capacity.

Non-compliance: Unwillingness of the patient toparticipate in health care activities.


2. Beneficence ( DO GOOD)

Beneficence is doing or promoting good.
This principle is the basis for all health care providers.
The principle of beneficence has three components:

Promote good
Prevent harm
Remove evil or harm

Ex. Nurses take beneficent actions when they administer pain medication, perform a
dressing to promote wound healing or providing emotional support to a client who is
anxious or depressed.


2. Nonmaleficience( DO NO HARM)

Nonmaleficence is the converse of beneficence. It means to avoid doing harm.
When working with clients, health care workers must not cause injury or suffering

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toclients.
It is to avoid causing deliberate harm, risk of harm and harm that occurs during the
performance of beneficial acts.
Nonmaleficence also means avoiding harm as a consequence of good. In that cases
the harm must be weighed against the expected benefit

Ex. Experimental research that have negative consequences on the client

4. Justice

Justice is fair, equitable and appropriate treatment. It is the basis for the obligation
to treat all clients in an equal and fair way.

5. Veracity

Veracity means telling the truth, which is essential to the integrity of the client-
provider relationship
Health care providers obliged to be honest with clients
The right to self-determination becomes meaningless if the client does not receive
accurate, unbiased, and understandable information

6. Fidelity

Fidelity means being faithful to one's commitments and promises.
Nurses commitments to clients include providing safe care and maintaining
competence in nursing practice.


6. Confidentiality

Confidentiality in the health care context is the requirement of health
professionals (HPs) to keep information obtained in the course of their work
private.
Confidentiality is non-disclosure of private or secret information with which one
is entrusted. Legally, this requirement applies to HPs and others, who have access
to information about patients, and continues after the patients death

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Nurses hold in confidence any information obtained in a professional capacity,
and use professional judgment in sharing such information.

Can Confidentiality Be Violated?

Disclosure of Information

Disclosure of information is not necessarily an actionable breach of confidence.
Disclosure may be allowed, under certain circumstances such as when it is requested by:

1. Bythe patient, and where it applies, freedom of information can be used by
patients to obtain health care information
2. Other health practitioners (with the patientsconsent, and where the information is
relevant to thepatients care)
3. Relatives in limited circumstances (e.g., parentswhen it is in the interests of the
child)
4. Researchers with ethics committee approval (andwhere the approved process is
followed)
5. The court
6. The media, if the patient has consented; and
7. The police, when the HP has a duty to provide the information. Unless there is a
warrant or a serious crime has been committed, the information provided to the
police is normally limited to the patients identity, general condition and an outline
of injuries.

III. LEGAL CONCEPTS IN NURSING

A. General Legal Concepts

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Law can be defined as those rules made by humanswho regulated social conduct in a
formally prescribed and legally binding manner. Laws are based upon concerns for fairness
and justice.

B. Functions of Law in Nursing

The law serves a number of functions in nursing:

It provides a framework for establishing which nursing actions in the care of client
are legal.
It differentiates the nurse's responsibilities from those of other health
professional.
It helps establish the boundaries of independent nursing action.
It assists in maintaining a standard of nursing practice by making nurses
accountable under the law.

C. Types of Law

Law governs the relationship of private individuals with government and with each other.

1. Public Law: refers to the body of law that deals with relationships between individuals
and governmental agencies. An important segment of public law is criminal law which
deals with actions against the safety and welfare of public. Example, theft, homicide.

2. Private Law : is the body of law that deals with relationships, between individuals. It is
categorized as contract law and tort law.

a. Contract Law: involves the enforcement of agreements among private
individuals or the payment of compensation for failure to fulfill the agreements.
b. Tort Law: the word tort means 'wrong " or "bad" in Latin. It defines and enforces
duties and rights among private individuals that are not based on contractual
agreements. Example of Tort law applicable to nursing

1. Negligence and malpractice

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2. Invasion of privacy and assault.

D. Kinds of Legal Actions

There are two kinds of legal actions

1) Civil actions: Deals with the relationships between individuals in a society.
Example, a man may file a suit against a person who he believes cheated him.

2) Criminal actions: Deals with disputes between an individual and the society as a
whole. Example if a man shoots a person, society brings him to trial.

E. Legal Issues in Nursing Practice

Nursing Practice Act: Legally define and describe the scope of nursing practice, which
the law seeks to regulate, thereby protecting the public as well.

Standard of Practice: A standard of practice is means which attempts to ensure that
its practitioners are competent and safe to practice through the establishment of
standard practice.

Credentialing: Credentialing is the process of determining and maintaining
competence nursing practice.

Credentials include:

a. Licensure
b. Registration
c. Certification
d. Accreditation


F. The Nursing Assistant Code of Ethics

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Code of ethics is formal statement of a groups ideas and values that serve as a
standards and guidelines for the groups professional actions and informs the public
of its commitment.

Codes of ethics are usually higher than legal standards, and they can never be less
than legal standards of the profession.

NURSING ASSISTANT CODE OF ETHICS
1. Help preserve life, ease patients suffering and work toward restoring health to all.
2. Consider all needs including social, physical, emotional and spiritual.
3. Be loyal to your employer, patients co-workers, and the facility in which you work.
4. Practice good health habits in order to keep your own good health. Sound health
habits include nutritious meals, sufficient rest and sleep , time for relaxation and
recreation when off duty, and prompt reporting of any sign of illness. Periodic health
check-ups are needed to prevent illness.
5. Be neat and well-groomed at all times while on duty and pay attention to your own
hygiene and cleanliness.
6. Give nursing care on the same level to all patients regardless of their racial or
religious beliefs. Show equal courtesy and respect to all patients.
7. Keep all information about patients and families confidential when outside the facility.
8. Carry out your duties responsibly and to the best of your ability. Be cooperative and
communicative when working with others and show respect for the work done by
others.
9. Never perform a procedure or give a treatment you are not qualified to perform. Do
not carry out a patients request unless positive it is appropriate to do so. Always
check first with nurse in charge.

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10. Never discuss your own personal problems and affairs with patients.
11. Make the patients welfare and safety the first concern.
12. Care for your patients as taught to do so, be willing to learn new skills and
update old ones.
13. Be flexible and willing to accept changes in tasks and assignments which will
improve the quality of patient care.
14. If the patients welfare and safety are in jeopardy by actions of other personnel,
you are obligated to make this known.
G. Common Legal Issues and Nursing Care Responsibilities

1. Abortion:

The nurse shall assist the physician if she/he is sure that an abortion is performed
for the purpose of saving the endangered life or health of women.
The nurse shall not attempt or carry out abortion
It is mandatory for the nurse to treat a patient who is suffering from the effect of a
criminal abortion induced by another provided there is no physician in the health
institution.
The nurse has all the right not to participate in all procedures of criminal abortion

2. Euthanasia

It is the act of pennilessly putting to death persons suffering from incurable or
distressing diseases. It is commonly referred as mercy killing
The nurse shall never assist; collaborate in taking life as an act of mercy even at
the direct request of the patient or patient's relatives.
All forms of euthanasia are illegal except in states where right to die status and
living will exist.


Types of Euthanasia

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1. Active euthanasia: Is a deliberate attempt to end life. e.g., deprivation of oxygen
supply, administering an agent that would result in death.

2. Passive euthanasia: allowing death by withdrawing or withholding treatment. No
special attempt will be made to revive the patient

3. Death

The nurse shall note the exact cessation of vital signs and notify the attending
physician to pronounce death.
The nurse shall give due respect to the deceased taking in to consideration
religion and cultural aspects.
A nurse shall participate in or assist a medical team in taking out organ from a
cadaver provided there is written consent of a patient or relatives

4. Suicide

A nurse who is taking care of a patient with a suicidal tendency shall remove all
items that facilitate suicide such as sharp instruments, ropes, belts, drugs and
make sure that the outlets are graded.
The nurse should not leave a suicidal patient alone

5. Organ donation:

The nurse shall involve in any organ transplantation procedure provided that the
donor and recipient have clear written agreement, the donor gives informed
consent and he/she is not mentally ill at the time of consent.

6. Autopsy

7. DNR orders


H. Areas of Potential Liabilities in Nursing Care

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a. Crimes and Torts
b. Privacy of Clients Information
c. Loss of Client Property
d. Unprofessional Conduct

a. Crimes and torts

CRIMES

A crime is an act committed in violation of public (criminal) law and punishable by
a fine and/ or imprisonment.

A crime does not have to be intended in order to be a crime. For example, a nurse
may accidentally give a client an additional and lethal dose of narcotic to relive
discomfort.

Crimes could be felonies and / or misdemeanors.

1) Felonies: a crime of a serious nature such as murder, armed robbery, second degree
murder. A crime is punished through criminal action by the state.

2) A misdemeanor: is an offense of a less serious nature and is usually punished a fine
or short term jail sentence or both. For example, a nurse who slaps a clients face
could be charged with a misdemeanor


TORTS

Torts are civil wrong committed against a person or a persons property. Torts are
usually litigated in court by civil action between individuals.

Tort may be classified as intentional or unintentional:

a. Intentional Torts

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1. Fraud: false presentation of some fact with the intention that it will be acted up on by
another person. Example, it is fraud for a nurse applying to a hospital for employment
to fail to list two past employers for deceptive reasons when asked for five previous
employers.


2. False imprisonment: unlawful restraint or detention of another person against his or
her wishes


3. Defamation: to attack somebody or somebody's reputation, character, or good name
by making slanderous(orally) or libelous (written) statements

4. Assault: an unlawful threat or attempt to do violence or harm to somebody else

5. Battery: the unlawful use of any physical force on another person, including beating
or offensive touching without the person's consent


b. Unintentional Torts

1. Malpractice

professional misconduct; illegal, unethical, negligent, or immoral behavior by
somebody in a professional or official position, resulting in a failure to fulfill the
duties or responsibilities associated with that position

2. Negligence:

a civil wrong tort causing injury or harm to another person or to property as the
result of doing something or failing to provide a proper or reasonable level of care.

I. Legal Protection in Nursing Practice


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1) Good Samaritan Act
2) Carrying Out Orders
3) Providing Competent Care
4) Documentation
5) Incident Report

RECORD KEEPING, REPORTING AND DOCUMENTING

Reporting: oral or written account of patient status between members of health care
team. Report should be clear, concise, and comprehensive.

Documenting: patient record/chart provides written documentation of patients status
and treatment

Purpose:continuity of care, legal document, research, statistics, education, audits

What to document: assessment, plan of care, nursing interventions (care, teaching,
safety measures), outcome of care, change in status, health care team
communication,

Characteristics of documentation: brief, concise,comprehensive, factual, descriptive,
objective, relevant/appropriate, legally prudent

RECORD KEEPING

Health records are the means by which information is communicated about clients
and means of ensuring continuity of care.

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The clients medical record is legal document and can be produced in a court as
evidence.
Records are used as risk management tools and for research purpose.
Often the record is used to remind a witness of events surrounding a lawsuit, because
several months or years usually elapse before the suit goes to trial.
Nurses need to keep accurate and complete records of nursing care provided to
clients.
Insufficient or inaccurate documentation:
o Can constitute negligence and be the basis for tort liability.
o Hinder proper diagnosis and treatment and result injury to the client.

Accurate Record Keeping

Routine nursing assessment and intervention should be documented properly.
Use pen rather than pencil during documentation.
When making correction do not raise the previous draw one line on an old and add
correction so the previous remained legible because correction is not for changing.
Write legibly.
Document all information.
Add time, date, name and other important information.
Document all medically related conditions.
Use specific terms and statements should not be biased.

THE INCIDENT REPORT

An incident report is an agency record of an accident or incident. Whenever a patient

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is injured or has a potential injury there exist a possibility of a lawsuit, such a report
must be recorded
An incidental report may be written for situations involving a patient, visitors, or
employee.
The incident report used to:
To make all the facts about an accident available to personnel
To contribute to statistical data about accidents or incidents.
To help health personnel to prevent future accidents.

N.B. the reports should be completed as soon as possible i.e., Within 24 hours of the
incident and filed according to agencies policy.

Information to include in incident report
Identify the client by name and hospitals

Give date and time of the incident. Avoid any conclusions or blame. Describe the
incident as you saw it even if you your impressions differ from those of others

Identify all witnesses to incident

Identify any equipment by number and any medication by name and number.

Document any circumstance surrounding the incident. For example, that another
client is experiencing cardiac arrest.


J. Reporting Crimes, Torts and Unsafe Practices

A nurse may need to report nursing colleagues or other health professionals for

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practices that endanger the health and safety of a client. For example, Alcohol and
drug use theft from a client or agency, and unsafe nursing practice.

Guidelines for reporting a crime, tort or unsafe practices are:
Write a clear description of a situation you believe you should report.
Make sure that your statements are accurate
Make sure you are credible
Obtain support from at least one trust worth person before filing the report
Report the matter starting at the lowest possible level in the agency hierarchy
Assume responsibility for reporting the individual by being open about it, sign
your name to the letter.
See the problem through once you have reported it.




A life lived for others is a life worthwhile