legal concerns of the patient care report quizlet

When to advise the receiving provider of a completed patient care report?

D) advise the receiving provider that he or she will return to the emergency department with the completed patient care report within 24 hours. 35. Additions or notations added to a completed patient care report by someone other than the original author:

What should the patient care report include?

The patient care report: A) provides for a continuum of patient care upon arrival at the hospital. B) is a legal document and should provide a brief description of the patient. C) should include the paramedic's subjective findings or personal thoughts.

What are the laws and regulations related to patient safety?

Forensic medicine aspect Laws and regulations related to patient safety, which may vary based on the legislation system of each country, should encourage the disclosure of medical errors while supporting the implementation of the ethical imperatives of patient safety.

What do nurses need to know about legal issues?

As with other educational needs, nurses provide educational activities to clients, significant others, and other staff members about legal issues that can impact on the care that they provide. Some of the conditions that nurses are mandated by law to report some communicable diseases, gunshot wounds, and child and/or elder abuse or neglect.

What should be included in a patient care report?

There are seven elements (at a minimum) that we have identified as essential components to documenting a well written and complete narrative.Dispatch & Response Summary. ... Scene Summary. ... HPI/Physical Exam. ... Interventions. ... Status Change. ... Safety Summary. ... Disposition.

What role does the health record play in the legal aspects of health care?

How does a health record serve as a legal document? It serves as the way to reconstruct an episode of patient care. This reconstruction provides the ability to prove what did or did not happen in a particular case and establish whether the applicable standard of care was met.

What is a component of the narrative section of a patient care report?

The narrative section of the PCR needs to include the following information: Time of events. Assessment findings. emergency medical care provided. changes in the patient after treatment.

Which of the following is a function of a prehospital care report quizlet?

What are main purposes of the prehospital care report? It serves as a record of patient care, as a legal document, provides information for administrative functions, aids education and research, and contributes to quality improvement.

What are some legal issues in health information management?

7 Current Legal Issues in HealthcareTelehealth law. ... HIPAA compliance and PHI. ... Healthcare employers liability & ensuring safe work conditions. ... Long-term care and nursing homes. ... False Claims Act. ... Patient safety and healthcare inequity. ... General access to healthcare.

What are the legal aspects of patient record?

LEGAL ASPECTS: Police authorities and court can summon medical records under the due process of law. Limitation period for filing a case paper is maximum up to 3 years under limitation Act. According to the consumer protection act it is up to 2 years.

What is a PCR document?

The PCR documentation is considered a medical document that becomes part of the patient's permanent medical record. It is also considered a legal document in cases where liability and/or malpractice issues arise. It is the source in which all medical billing claims are based.

What is the purpose of the narrative section of the patient care report?

Detailed explanation of medical necessity: Your narrative should be detailed and provide a clear explanation for why the patient needed to be transported by ambulance. Include what the medical reasons were that prevented the patient from being transported by any other means.

Why is it important for a health care provider to maintain accurate patient records?

Complete and accurate medical recordkeeping can help ensure that your patients get the right care at the right time. At the end of the day, that's what really matters. Good documentation is important to protect you the provider. Good documentation can help you avoid liability and keep out of fraud and abuse trouble.

When you document information on a patient that you treat and care for this written report is called the?

When you document information on a patient that you treat and care for. This written report is called the: Patient care report, run report. You are asked to give testimony in court about the care you gave to a patient.

How many sets of vital signs should be included in the patient care report?

At least two complete sets of vital signs should be taken and recorded.

When completing the prehospital care report PCR what should be included in it?

According to the NHTSA, in addition to other data elements, the minimum data set on a prehospital care report (PCR) should include all of the following: respiratory rate and effort & skin color and temperature; times of incident, dispatch, and arrival of patient; capillary refill for patients less than 6 years old.

What is ethical dilemma?

A common ethical dilemma is a client's or client's family's desire to continue an activity at risk. In general, an individual has the autonomy to choose this unless he or she is declared incompetent. 11. An older adult client with urosepsis has become nonresponsive.

Why do children of a nursing home have approached the nurse?

The children of a resident of a nursing home have approached the nurse because they believe their parent is being manipulated by a person who also lives in the facility. Their parent has a diagnosis of early-stage Alzheimer disease and various comorbidities that affect mobility and function.

What are some torts that are specific to nursing?

Some torts specific to nursing and nursing practice include things like malpractice, negligence and violations relating to patient confidentiality. (Berman and Synder, 2012) Unintentional Torts: Unintentional torts include things like malpractice and negligence. Intentional Torts: Intentional torts include things like false imprisonment, assault, ...

What is negligence in nursing?

Negligence occurs when the nurse fails to follow established policies, procedures and standards of care in the same manner that another "reasonable" nurse would do in the same situation . (Berman and Synder, 2012) Malpractice: Malpractice, also a nonintentional tort, has six elements.

What is civil law?

Civil Law: Civil law, also part of public law, covers torts and contract laws. (Berman and Synder, 2012) Torts: Torts are civil laws that address the legal rights of patients and the responsibilities of the nurse in the nurse patient relationship. Some torts specific to nursing and nursing practice include things like malpractice, ...

What are the elements of malpractice?

The elements of malpractice include a duty, a breach of duty as a nurse, reasonable foreseeability that the nurse's act has a connection with the patient injury that occurred, the patient was harmed, the link that act directly led to the harm and the patient has the right to financial compensation or damages.

What are intentional torts?

Intentional Torts: Intentional torts include things like false imprisonment, assault, battery, breaches of privacy and patient confidentiality, slander and libel. Liability: Liability is vulnerability and legal responsibility, simply stated. For example, nurses are liable when they fail to carry out doctor's orders.

What is common law?

Common Law: Common law is law that results from previous legal decisions. They are based on legal precedent. (Berman and Synder, 2012) Statutory Law: Statutory law is law that is passed by a legislative body such as the state's legislature or the US Congress. (Berman and Synder, 2012)

Do nurses have to follow federal laws?

In addition to following the policies and procedures of the particular employing healthcare organization, nurses must also follow and comply with any federal and state laws relating to interpreters and serving as an interpreter.