PERIOPERATIVE NURSING

Legal Aspects
PREPARED BY: Joseph Emmanuel D. Sakay, RN
Key Concepts Related to Legal Issues
• Negligence vs. Malpractice
– Statutory Law
• Guards the morals, safety,
order, and welfare of the
citizens
– Common Law
• Based on the principles and
rules of action relating to the
security of the individuals and
their property
 Legal Doctrines
• Captain of the Ship Doctrine
• The Borrowed Servant Doctrine
• The Respondeat Superior Doctrine
• Res Ipsa Liquitur - “The thing speaks for itself”
 Informed Consents
• Authorizes specific treatment/care
and it authorizes the person
administering it.

• Informed – refers to the information

given to the patient about a
proposed procedure or treatment
• Consent – refers to the patient’s
agreement to the procedure or
treatment
Informed Consent
• Elements
– Voluntary
– Patient must be fully informed
– Given by a person with legal
capacity

• Reasonable patient standard

• Reasonable physician standard
 Informed Consent
– A fair explanation of the condition, procedure and
possible risk and benefits
– Description of possible alternatives
– Time for decision making
– Absence of undue pressure
 Informed Consent
• Refusal to Consent
– Patient can refuse
• Ask patient to sign a waiver to protect institution
• Document and notify appropriate authorities
– Exception to the rule
• In case of life or limb emergency
• Disclosure of information cause additional damage
• If patient chose not to hear all info, must sign a waiver
giving up the right to full disclosure
 Documenting Perioperative
Nursing Care
• The patient’s record should reflect:
– The preoperative assessment and planning carried
out by the perioperative nurse
– Care given by members of the surgical team and its
outcomes. The care should be documented on the
patient’s chart
– A continued evaluation of the perioperative
nursing care and the patient responses to nursing
interventions
• Documentation will be determined by policies
and procedures of the practice setting
 Nine Pitfalls of Documentation
• Omission of Information
• Personal Opinion
• Generalizations
• Late (Retrospective) Charting
• Improper use of Abbreviations
• Illegibility
 Nine Pitfalls of Documentation
• Incorrect Spelling
• Improper Error Correction
• Improper Signature
Sponge, Sharp, And Instrument Counts

• A legal responsibility of the surgical team, with

complete documentation of the count status
entered on the intraoperative record by the
circulating nurse

• Sponge, Surgical needle and blades, and

Instruments
 When to count?
• Preliminary count done before the procedure
• Start counting during the procedure
• Final count done before closing
• Recount after the procedure