Health Assessment

(Finals)
Legal and Ethical Aspects in Nursing

Law
- Defined as the principles and regulations established in a community by
some authority and applicable to its people whether I the form of legislation
or of custom and policies recognized by judicial decision.

Types of Law
 Contract Law – concerned with enforcement of agreements among
private individuals.
 Civil Law - concerned with relationships among persons and the
protection of a person’s rights. Violation may cause harm to an individual
or property, but no gave thread to society exists.
 Criminal Law – concerned with relationships between individuals and
governments, and with acts that threaten society and its order; a crime is
an offense against society that violates a law and it’s defined as
misdemeanor (less serious nature) or felony (serious nature).
 Tort Law – a civil wrong, other than a beach in contract, in which the law
allows an injured person to seek damages from the person who caused
the injury.

Intentional Torts
- Torts actionable upon evidence of an intent to cause harm on another.
 Assault
 Battery
 False Imprisonment
 Invasion of Privacy
 Fraud
 Defamation

Assault
- Any intentional threat to bring about harmful or offensive contact with
another individual, no actual contact is necessary.
- Example: Threatening a patient to give an injection.
- Restrain a patient from an x-ray procedure when the patient has refused
consent.
Battery
- An intentional touching without consent, the contact is harmful to the
patient and causes an injury, or it is merely offensive to the patient’s dignity.
- Example: Giving an injection without the patient’s consent.
- A patient gives consent for left knee repair, but the surgeon performs right
knee surgery.

False Imprisonment
- Making a person stay in pace against is wishes is false imprisonment.
- Example: Restraining or confining a patient to a locked room without proper
consent could constitute false imprisonment.

Invasion of Privacy
- Is a direct wrong of a personal nature.
- It injures the feeling of a person and does not take into account the effect of
revealed information on the reputation of the person in the community.
- The right to privacy is the right of individuals to withhold themselves and
their lives from public scrutiny.

Fraud
- A willful and purposeful misrepresentation that could cause or cased harm
to a person or property.
- Example: Giving incorrect information to obtain a better position or job.

Defamation
- Is communication that is false, or made with a careless disregard for the
truth, results in injury to the reputation of a person.
 Libel – is defamation by means print, writing or pictures.
 Slander – is defamation by spoken word, stating unprivileged (not legally
protected) or false words by which a reputation is damaged.

Unintentional Torts
 Negligence – is a failure to use reasonable care or doing of something
which a reasonably prudent person would not do.
 Malpractice – is a legal cause of action that occurs when a medical or
health care professional deviates from standards in his or her profession.
Common Sources of Negligence and Malpractice
- Medication errors that result in injury to patient.
- Burns caused by equipment or spills of hot liquids.
- Falls in sponge, instrument, needle, count in surgery cases.
- Failure to give adequate report, notify physician, adequate monitoring the
patient.
Legal Safeguards for Nurses
- Informed consent is a patient’s agreement to allow something to happen,
such as surgery based on a full disclosure of risks, benefits alternatives and
consequences of refusal (Black, 1999).
 Documentation
 Executing Physician’s Order
 Good Samaritan Law (HB 3474)
 Patient Education

Concepts of Consent:
- Client’s questions about the surgery/procedure must be answered before
signing consent.
- Must be signed freely by the client without threat or pressure and must be
witnessed (witnesses must be an adult).
- Client’s medicated with sedating medications or any medications affecting
cognitive function should not sign a consent.
- Legally, the client must be mentally and emotionally competent to give
consent.
- Consent can be withdrawn anytime.
- Can be waived for urgent medical or surgical intervention as long as
institutional policy so indicates.

Legal Issues Related To Nursing

 Confidentiality
 Advance directives – are legal documents stating the wishes of
individuals regarding health care in institutions in which they are no
longer capable of giving personal informed consent.

- Autopsies
- Termination of life-sustaining treatment
- Do not resuscitate / CPR (DNR/DNC) orders
Organ and Tissue Donation
Types: Live Donation and Cadaveric donation

RA 7170 – The transplantation of human organs act, 1991

- An act to provide for the regulation of removal, storage, and transplantation
of unman organs for therapeutic purposes and for the prevention of
commercial dealings in human organs and for matter connected with it.

Senate Bill 666 – Transplantation of human organs bill 2013

Laws Related to Mental Health Nursing

 RA 9165-Dangerous Drugs Act, 2002
 RA 11036-Mental health act ,2017

What are the Laws Affecting Nursing Practice in the Philippines?

 RA 9173-Philippine Nursing Act of 2002
 RA 9181-PRC Modernization Act, 2000: Highlight-Reciprocity Provisions

PRC Resolution No.2012-668 series of 2012:

- Guidelines for Implementing Paragraph J, L and Sec. 16 of RA 9181: issuance
of PIC and COR for a foreigner registered in his/her country duly registered to
practice in the Philippines.

Concepts of Licensing in the Philippines of a Registered Nurse:

License - This is the legal permit that grants individuals to engage in
professional practice.

Nursing Licensure Examination (NLE) Qualifications

- Before considering filing your application for the licensure examination, it’s
best to identify if you’re qualified to take the board exam. Check the full
qualifications below:
 He or she must be a citizen of the Philippines.
 Must be at least eighteen (18) years of age at the time of the issuance of
a certificate of registration.
 He or she holds a bachelor's degree in nursing from a college or
university duly recognized by the proper government agency.
Nursing Licensure Examination (NLE) Coverage
The Nursing Licensure Examination (NLE) consists of five subjects:
1. Nursing Practice I – Community Health Nursing
2. Nursing Practice II – Care of Healthy / At Risk Mother and Child
3. Nursing Practice III - Care of Clients with Physiologic and Psychological
Alteration (Part A)
4. Nursing Practice III - Care of Clients with Physiologic and Psychological
Alteration (Part B)
5. Nursing Practice III - Care of Clients with Physiologic and Psychological
Alteration (Part C)
The examination covers basic skills, knowledge, attitude in the major subject
areas: maternal and child nursing, fundamentals of nursing including
professional adjustments, community health and communicable disease
nursing, nursing of adolescents, adult and aged, psychiatric nursing, and
mental health.

Nursing Licensure Examination (NLE) Passing Rate

For an examinee to become a registered nurse in the Philippines, they first
must obtain a general average rating of at least 75%, with a rating of not
below 60% in any of the five subjects.
However, suppose the examinee receives a passing score or higher in the
general average rating but gets rating below 60% in any of the five subjects. In
that case, the examinee must take the examination again, but only in the
subject/s where the examinate rated below 60%.

What are the Laws Affecting Nursing Practice in the Philippines?

 RA 10173-Data Privacy Act, 2012
 RA 7877-Anti-Sexual Harassment Act, 1995
 RA 9003-Ecological Solid Waste Management Act, 2000

Philippine Nursing Profession Roadmap 2030:

- The pathway from compliant to proficient status of nursing profession.
Ethical Aspects in Nursing

Ethics
- The word ethics derived from the Greek term ethos, which means ‘customs`.
- Defined as a branch of philosophy that involves systematizing, defending,
and recommending concepts of right and wrong conduct, often addressing
disputes of moral diversity (Wikipedia).

Ethical Principles
 Autonomy
 Beneficence
 Nonmaleficence
 Fidelity
 Justice
 Veracity

Autonomy
- It involves the right of self-determination or choice, independence, and
freedom.
- Example: The purpose of the preoperative consent is to assure in writing
that the health care team respects the patient’s independence by obtaining
permission to proceed.

Beneficence
- This principle promotes taking positive, active steps to help others.
- Example: A child immunization causes discomfort during administration but
the benefits of protection from disease both individual and for society,
outweigh the temporary discomforts.

Nonmaleficence
- It refers to the fundamental agreement to do no harm.
- Example: While catching a client who is falling, the nurse grips the client
tightly enough to cause bruises to the client’s arm.
Fidelity
- It refers to the agreement to keep promises, commitments, responsibilities
that one has made oneself and others.
- Example: if you assess a patient for pain and then offer a plan to manage it,
this principle encourages you to do your best to keep the promise to improve
the patient’s comfort

Justice
- It refers principle of fairness
- It implies equal treatment of all clients.
- Example: A national multidisciplinary committee strives for fairness by
ranking recipients according to need, rather than resorting to selling organs.

Veracity
- Placebo: A placebo is a substance or treatment which is designed to have no
therapeutic value. Common placebos include inert tablets, inert injections,
sham surgery, and other procedures.

Code of Ethics
- Code of ethics is defined as `a specific set of professional behaviors and
values the professional interpreter must know and abide by including
confidentiality, accuracy, privacy, integrity.

Ethical Rights
- Based on an ethical principle and are often privileges allotted to individuals.

Ethical Dilemma
- A situation in which a choice must be made between two equally
undesirable actions.

Ethical Problems in Nursing

1. Staff shortage
2. Cultural and religious sensitivity
3. Delegation
4. Truth telling vs Deception
A Patient’s Bill of Rights

Bill of Rights
- These rights can be exercised on the patient’s behalf by a designated
surrogate or proxy decision maker if the patient lacks decision-making
capacity, is legally incompetent, or is a minor.

The patient has the right to be considerate and receive respectful care.

 The patient has the right to and is encouraged to obtain from physicians
and other direct caregivers relevant, current, and understandable
information concerning diagnosis, treatment, and prognosis.

- Except in emergencies when the patient lacks decision making capacity and
the need for treatment is urgent, the patient is entitled to the opportunity to
discuss and request information related to the specific procedures and/or
treatments, the risks involved, the possible length of recuperation, and the
medically reasonable alternatives and their accompanying risks and benefits.

- Patients have the right to know the identity of physicians, nurses, and others
involved in their care, as well as when those involved are students, residents,
or other trainees. The patient also has the right to know the immediate and
long-term financial implications of treatment choices, insofar as they are
known.

 The patient has the right to make decisions about the plan of care prior
to and during the course of treatment and to refuse a recommended
treatment or plan of care to the extent permitted by law and hospital
policy and to be informed of the medical consequences of this action.

- In case of such refusal, the patient is entitled to other appropriate care and
services that the hospital provides or transfers to another hospital. The
hospital should notify patients of any policy that might affect patient choice
within the institution.
 The patient has the right to have an advance directive (such as a living
will, health care proxy, or durable power of attorney for health care)
concerning treatment or designating a surrogate decision maker with the
expectation that the hospital will honor the intent of that directive to
the extent permitted by law and hospital policy.

- Health care institutions must advise patients of their rights under state law
and hospital policy to make informed medical choices, ask if the patient has
an advance directive, and include that information in patient records. The
patient has the right to timely information about hospital policy that may
limit its ability to implement fully a legally valid advance directive.

 The patient has the right to every consideration of privacy. Case

discussion, consultation, examination, and treatment should be
conducted so as to protect each patient's privacy.

 The patient has the right to make decisions about the plan of care prior
to and during the course of treatment and to refuse a recommended
treatment or plan of care to the extent permitted by law and hospital
policy and to be informed of the medical consequences of this action.

- The patient has the right to expect that the hospital will emphasize the
confidentiality of this information when it releases it to any other parties
entitled to review information in these records.

 The patient has the right to review the records pertaining to his/her
medical care and to have the information explained or interpreted as
necessary, except when restricted by law.

 The patient has the right to expect that, within its capacity and policies,
a hospital will make a reasonable response to the request of a patient for
appropriate and medically indicated care and services.
- The hospital must provide evaluation, service, and/or referral as indicated by
the urgency of the case. When medically appropriate and legally permissible,
or when a patient has so requested, a patient may be transferred to another
facility. The institution to which the patient is to be transferred must first have
accepted the patient for transfer. The patient must also have the benefit of
complete information and explanation concerning the need for, risks,
benefits, and alternatives to such a transfer.

 The patient has the right to ask and be informed of the existence of
business relationships among the hospital, educational institutions,
other health care providers, or payers that may influence the patient's
treatment and care.

 The patient has the right to consent to or decline to participate in

proposed research studies or human experimentation affecting care and
treatment or requiring direct patient involvement, and to have those
studies fully explained prior to consent.

- A patient who declines to participate in research or experimentation is

entitled to the most effective care that the hospital can otherwise provide.

 The patient has the right to expect reasonable continuity of care when
appropriate and to be informed by physicians and other caregivers of
available and realistic patient care options when hospital care is no
longer appropriate.

 The patient has the right to make decisions about the plan of care prior
to and during the course of treatment and to refuse a recommended
treatment or plan of care to the extent permitted by law and hospital
policy and to be informed of the medical consequences of this action.

- The patient has the right to be informed of the hospital’s charges for
services and available payment methods.

Conclusion
Hospitals have many functions to perform, including the enhancement of
health status, health promotion, and the prevention and treatment of injury
and disease; the immediate and ongoing care and rehabilitation of patients;
the education of health professionals, patients, and the community; and
research. All these activities must be conducted with an overriding concern
for the values and dignity of patients.

Core Values of Nursing in Conducting Health Assessment

- Adopt the nursing core values in the practice of the profession.
- Adopt nursing core values in performing health assessment.
- Demonstrate caring as the core of nursing, love of God, love of country and
love of people when performing health assessment.

The Core Values Every Nursing School Should Have

 Empathy and Caring. A nursing school should teach its students the
true value of empathy and compassionate care.
 Communication
 Teaching
 Critical Thinking
 Psychomotor Skills
 Applied Therapeutics
 Ethical and Legal Considerations
 Professionalism

Caring as the Core of Nursing Practice

- Florence Nightingale (1860) defined nursing as having “charge of the
personal health of somebody…and what nursing has to do…is to put the
patient in the best condition for nature to act upon him.”

- And at the very core of nursing practice is the act of caring. Caring and
nursing are so intertwined that nursing would not be nursing without the act
of caring. Caring is “a feeling and exhibiting concern and empathy for
others, showing or having compassion” (The Free Dictionary, 2015). Caring is
a feeling that also requires action. The American Association of Colleges of
Nursing (2008) and the National League for Nursing (2007) have identified
caring as a foundational value for nursing.
Are You Going to be a Caring Nurse?
- In a study done by Rhodes, Morris, Lazenby (2011), over two-thirds of
subjects expressed caring as an essential Nursing characteristic. Many
described caring as “essential,” “the most important trait,” “central to
nursing,” or “critical to the role.” A caring nurse can cause patients “not to be
scared,” Others indicated that caring separated nursing from other
professions and is essential for providing holistic care. Other comments
included “without caring…not a nurse” and “even if no one else cares, nurses
do.”

Charting

Uses for the Medical Record

 Permanent account
 Tracks pt progress/care given
 Sharing information
 Patient confidentiality
 Quality assurance
 Accreditation
 6 items that must be documented
 Insurance reimbursement
 Research
 Legal evidence for malpractice suits
 Assures continuity of care

Permanent Record
- Written in chronological order
- Filed in medical records dept for future use/reference.

Sharing Information
- Facilitates exchange of information between staff.
- Prevents duplication errors (Meds, dressing change, activity, diets, etc.)

Patient Confidentiality
- Never leave chart in a public place.
- Discuss contents only with persons directly involved in the patient’s care or
those that are authorized by the patient. These people should be listed by
name.
- Ask for id prior.
- Do not discuss pt or pt info in public places. (Example: Elevators, cafeteria)

Quality Assurance
- A peer review process conducted by a staff nurse and physician.
- Establishes and reflects agency standards.

Accreditation
- JCAHO (Joint Commission on Accreditation of Health Organization)/DSHS
STATE (Extended Care)
- Sets minimum standards for staffing.
- The American nurses association sets the standards for pt care &
documentation for nurse’s

6 Items that Nurses Must Document

- Assessment
- Nursing dx and pt needs
- Interventions
- Care provided
- Patient response to care
- Patients ability to manage continuing care after discharge

Reimbursement
- Lack of documentation may result in denial of payments from Medicare and
private insurance companies. This puts the burden of payment on the
patient.

Research
- Data on treatments, meds, and therapy
- Info for tumor boards, doctor’s rounds, nursing rounds, etc.
- Be aware of privacy issues
- Nurses, student nurses use for care plans.

Legal Evidence
- Records are considered legal or potential legal documents
- May be subpoenaed as evidence by attorney or nursing boards. Check for
deviations from facility policy or standards.
- Each health care provider is responsible for the ABC’s of recording.
Accuracy, brief, complete.

Access to Charts
 Patient’s rights
 Who owns chart
 Agency policy

Patient’s Rights/Agency Policy

- Patients have the right to the info in their charts.
- They do not have the right to see the chart on demand or remove anything
from the chart or remove the chart from the facility.

Who Owns the Chart

- A patient’s chart is the property of the facility. It is the facility which sets the
policy and makes appointments for viewing of the chart.

Types of Patient Records

 Source-Oriented
 Problem-Oriented

Source oriented
- Most traditional
- Different disciplines chart on separate forms.
- Each reader must consult various parts of the record to get a complete
picture.
- Records become bulky.

Problem Oriented
- Commonly referred to as por.
- Organized according to problem.
- Four parts:
a. Data base - the patients present health status.
b. Problem list - numbered list of health problems.
c. Initial plan - plan to help overcome health problems.
 d. Progress notes - all disciplines chart on same page

Methods (Styles) Of Charting

 Narrative
 SOAP - SOAPIER
 Focus – data, action, response
 Pie
 Exception charting

Narrative
- Chronological
- Baseline charted qshift
- Lengthy, time-consuming
- Separate pages for each
- Source-oriented

SOAP
- Used for problem-oriented charts

S – subjective. What patient tells you.

0 – objective. What you observe, see.
A – assessment. What you think is going on based on your data.
P – plan. What you are going to do.

- Can add to better reflect nursing process.

I – intervention (specific interventions implemented)
E – evaluation. Pt response to interventions.
R – revision. Changes in treatment.

- Example Of Soap Charting: Alteration in comfort Abdominal pain.

 S – complains of pain in RUQ
 O – is pale and holding right side
 A – recurring abdominal pain
 P – put on NPO and notify physician

Focus Charting
- Uses narrative documentation (DAR)

Data – subjective or objective that supports the focus (concern)

Action – nursing intervention
Response – patient response to intervention

- Example of focus charting

 D – complaining of pain at incision site on level of #7
 A – repositioned for comfort. Demerol 50mg IM given.
 R – (charted at a later date.) States a decrease in pain, “feels much
better.”

Pie Charting
- Similar to SOAP charting
- Both are problem-oriented
- PIE comes from the Nursing Process, SOAP comes from a Medical Model.

P-Problem
I-Intervention
E-Evaluation

- Sample of pie charting

 P#1 - Risk for trauma related to dizziness.
 IP#1 - Instructed to call for assistance when getting OOB. Call light in
reach.
 EP#1 - Consistently call for assistance before getting OOB. Continues to
experience dizziness.

Charting By Exception
- Uses flowsheets.
- Emphasis on abnormal (what is abnormal for this patient.
- Although it may be abnormal for the “normal” person, if it is abnormal for
your patient on a consistent basis, it is no longer considered an “exception”.
- Advantage

Computerized Charting
- Password. Never share. Change frequently.
- Legible
- Can be voice-activated, touch-activated.
- Date and time automatically recorded.
- Abbreviations and terms are selected by a menu provided by the facility.
- Terminals are usually easily accessible, in pt rooms, convenient hallway
locations.
- Make sure terminals cannot be viewed by unauthorized persons.

Kardex
- Quick reference
- Changed as needed
- Not part of permanent record

Abbreviations
- You must use your facility’s approved abbreviations.
- Be aware that a lot of commonly used abbreviations
- Example: TID, BID, QOD, HS are no longer allowed and should be currently
being phased out of your facility.

Change Of Shift Report

- Person to person
- Be prepared
- Avoid gossip/socialization
- Tape recorder

Incident Reports
- Objective
- Do not blame or admit liability
- What did you do?
- Do not include names/addresses of witnesses
- Document time/name of doctor
- Do not file in chart
- Do not write “incident report made”

Correcting Errors
- If you spill something on the chart, do not discard notes. Recopy, put
original and copied sheets in chart. Write “copied” on copy.
- Do not scribble out charting.
- Avoid using “error” or “wrong patient” when making correction.
- Follow your facilities policy.
- Do not alter charting, it is a legal document.

Health Care Team in Health Assessment

The Role of Nurses

Team-based care
- Of a learning health system.
- It stresses interdependence, efficient care coordination, and a culture that
encourages parity among all team members (IOM, 2001, 2007).
- Teamwork should be reinforced at all levels, from leadership to the unit
level, and individual patients should understand that they are working with a
team

Health Care
- An increasingly diverse field where many specialties interact to provide
patient care.

The Team Approach to Caring for Patients

- Includes many professionals performing a variety of specialized functions
designed to meet the physical, emotional, and psychological needs of the
patient. In the course of just one stay, a hospitalized patient may be cared for
by an array of non-MD providers.

Collaborative Approach to Work

- Is imperative that all healthcare professionals understand and respect the
credentials, scope of practice and function of each member of the health care
team.

Nurses Role in the Health Care System

The Primary Role of a Nurse
- Is to advocate and care for individuals of all ethnic origins and religious
backgrounds and support them through health and illness.
- Collaborate with team to plan for patient care. Advocate for health and
wellbeing of patients.

Nursing
- Is an honorable profession, and nurses are the heart and soul of the
healthcare system.
- Nurses are on the frontlines of administering and evaluating treatment
- Nurses are the patient’s greatest advocates. Because they spend more time,
nurses can comprehensively moderate the patient’s progress.

The Multidisciplinary Team

- Is a group of health care workers who are members of different disciplines
(professions e.g., Psychiatrists, Social Workers, etc.), each providing specific
services to the patient.
- This coordinates their services and gets the team working together towards
a specific set of goals.
- Convey many benefits to both the patients and the health professionals
working on the team. These include improved health outcomes and
enhanced satisfaction for clients.

Members of the Health Care Team

- The Medical Doctor or Physician, a physician, medical practitioner, medical
doctor, or simply doctor, is a professional who practices medicine, which is
concerned with promoting, maintaining, or restoring health through the
study, diagnosis, prognosis and treatment of disease, injury, and other
physical and mental impairments.

The Nurse Practitioner

  Nurse practitioners are licensed registered nurses who have completed
advanced academic and supervised clinical training beyond their
registered nurse certification.
 Most have master’s degrees, and many have doctoral degrees.
 Nurse practitioners provide a number of
 different health care services.
 They are trained to diagnose and treat a variety of conditions, and can
order and interpret diagnostic tests and procedures, perform health
screenings, give immunizations, and may prescribe most medications.
 Nurse practitioners often focus on health promotion, disease
prevention and helping patients make healthy lifestyle choices. They
treat patients in outpatient settings and in the hospital.
 Although most nurse practitioners focus on primary care, many train
and practice in fields as diverse as OB/GYN, pediatrics, oncology,
dermatology, and other specialties.

The Registered Midwife / Certified midwives

- Are trained in midwifery.
- They must pass a national certification exam in order to be licensed to
practice.
- Certified midwives provide health care for women including prenatal care,
labor and delivery, post-partum care, routine gynecological services, family
planning, menopausal care, health promotion and disease prevention.
- Most certified midwives work in group practices with physicians and deliver
babies to birth centers or hospitals.

The Registered Dietitian

- Have earned a bachelor’s degree in dietetics or nutrition.
- Dietitians complete an approved practical education program and must pass
a national examination.
- The dietitian is the food and nutrition expert on the health care team.
- Dietitians help design food plans and educate and counsel patients to help
them manage disease states such as obesity, high cholesterol, or heart
disease.
- Many dietitians specialize in areas such as pediatrics, geriatrics, renal
disease, or diabetes education.
- Dietitians are also involved in hospital food service management and clinical
research.

The Registered Pharmacist

- Are medication experts, working with physicians (or PAs) to ensure new
prescriptions do not interact with a patient’s current medications, that the
right dosage for a particular medication has been prescribed, and to answer
any questions patients may have.

The Occupational Therapist

- Work with individuals of all demographics to regain, master, or develop the
everyday skills that enable them to lead fulfilling, independent lives.
- OT’s possess a graduate level degree in occupational therapy.
- They develop activities of daily living for individuals with mental or physical
disabilities that inhibit their capacity to function independently.
- With time, routines may be developed which help equip these patients to
pursue education and employment.
- OT’s are most frequently found in the hospital or outpatient rehabilitation
setting.

The Physical Therapist

- Similar to Occupational Therapist
- Who treats individuals whose medical problems or other health-related
conditions impair their ability to move and perform activities of daily living.
- Treatment plans focus on preventing further disability, alleviating pain, and
restoring function.
- Educational programs for PT’s exist at both the master’s and doctoral level.

The Respiratory Therapist

- Help evaluate and treat individuals suffering from respiratory ailments,
injuries that involve the respiratory tract, need pulmonary rehabilitation, or
who require augmented or mechanical ventilation.
- They are all graduates of an approved college program in Respiratory
Therapy, have completed their licensure requirements, and passed a
nationally administered advanced practice examination.
- RT’s practice primarily in the hospital and long-term care settings, where
they are an integral member of the patient care team.
The Medical Technologists
- Also known as Medical laboratory scientist, Clinical Laboratory Scientist,
Medical Laboratory Technologist, or Med-Tech
- Is an allied health professional that analyzes and tests body fluids and
tissues.

The Anesthesiologist
- Is a doctor (MD or DO)
- Who practices anesthesia.
- Anesthesiologists are physicians specializing in perioperative care,
developing anesthetic plans, and the administration of anesthetics.
- He or she has finished college, then medical school (four years), then an
internship (one year) followed by a residency in anesthesia (three years).
- Some anesthesiologists pursue additional years of training (a fellowship).
- Anesthesiologists help ensure the safety of patients undergoing surgery.
- The anesthesiologist provides care for the patient to prevent the pain and
distress they would otherwise experience.

The Ultra Sonographer

- Or diagnostic ultrasound technician
- Is a medical professional who uses equipment that produces sound waves of
high frequency for non-invasive diagnostic procedures.
- An ultra sonographer may work in a variety of specific areas to diagnose
health problems.
- A sonographer is a healthcare professional who specializes in the use of
ultrasonic imaging devices to produce diagnostic images, scans, videos or 3D
volumes of anatomy and diagnostic data, frequently a radiographer but may
be any healthcare professional with the appropriate

- The future of health care lies in successful collaboration among all of these
disciplines. It is essential for medical and other health professional students
to learn how to work with other clinicians in hospitals and other practice
sites. Each of these professionals brings a unique skill set and viewpoint to
the management of patient care. An environment of mutual respect and trust
among health care providers will promote excellent care and improve patient
outcomes.
Validating, Documenting and Reporting Data

Validating Data
- is the process of confirming or verifying that the subjective and objective
data you have collected is reliable and accurate.

Steps of Validation
 Deciding whether the data requires validation.
 Determining ways to validate the data.
 Identifying areas for which data are missing.

Data Requiring Validation

- Conditions that require data to be rechecked and validated include:
 Discrepancies or gaps between subjective and objective data.
 Discrepancies or gaps between what the client says at one time versus
another time.
 Findings that are highly abnormal and/or inconsistent with other
findings.

Methods of Validation
- Recheck your own data through a repeat assessment.
- Clarify data with the client by asking additional questions.
- Verify the data with another health care professional.
- Compare your objective findings with your subjective findings to uncover
discrepancies.
Documentation as Communication
- Is defined as written evidence of:
 The interactions between and among health professionals, clients, their
families, and health care organizations
 The administration of tests, procedures, treatments, and client
education
 The results or client’s response to these diagnostic tests and
interventions
- Nurses rely on charting, records, and systems that support the
implementation of the nursing process.
- Systematic documentation is critical to presenting the care administered by
nurses in a logical fashion.
- Critical thinking skills, judgments, and evaluation must be clearly
communicated through proper documentation.

Purposes of Health Care Documentation

 Professional Responsibility and Accountability
 Communication
 Education
 Research
 Legal and Practice Standards

- Recording provides written evidence of what was done for the client, the
client’s response, and any revisions made in the care plan.
- Recording documents compliance with professional practice standards and
accreditation criteria.
- Written records are a resource for review, audit, reimbursement, and
research.
- Documentation provides a written legal record to protect the client,
institution, and practitioner.

Education
- Health care students use medical records as a tool to learn about disease
processes, diagnoses, complications, and interventions.
- Clinical rounds and case conferences rely heavily on information contained
in the medical record.

Research
- Researchers rely heavily on medical records as a source of clinical data.
- Documentation can validate the need for research.

Legal and Practice Standards

- In 80% to 85% of malpractice lawsuits involving client care, the medical
record is the determining factor in providing proof of significant events.
  Informed Consent
 Advance Directives
 American Nurses Association (ANA) Standards of Care
 State Nurse Practice Acts
 Joint Commission on Accreditation of Health Care Organizations
(JCAHO)

Principles of Effective Documentation

- Nursing notes must be logical, focused, and relevant to care, and must
represent each phase of the nursing process.
- Nursing documentation based on the nursing process facilitates effective
care.

Elements of Effective Documentation

 Use of Common Vocabulary
 Legibility
 Abbreviations and Symbols
 Organization
 Accuracy
 Documenting a Medication Error
 Confidentiality

Use of Common Vocabulary

- Enhances the quality of documentation.
- Supports the efforts of research.
- Improves communication and lessens the chance of misunderstanding
between members of the health team.

Legibility
- Print if necessary.
- Do not erase or obliterate writing.
- Draw one line through an erroneous entry.
- State the reason for the error.
- Sign and date the correction.
- If you spill something on the chart, do not discard notes. Recopy, put
original and copied sheets in chart. Write “copied” on copy.
- Do not alter charting. It is a legal document.
Abbreviations and Symbols
- Always refer to the facility’s approved listing.
- Avoid abbreviations that can be misunderstood.

Organization
- Start every entry with the date and time.
- Chart in chronological order.
- Chart in a timely fashion to avoid omissions.
- Chart medications immediately after administration.
- Sign your name after each entry.

Accuracy
- Use factual, descriptive terms to chart exactly what was observed or done.
- Use correct spelling and grammar.
- Write complete sentences.
- Maintain continuity of care by recording with respect to notes made on
previous shifts.

Documenting a Medication Error

- Chart the medication on the MAR.
- Document in the nurses’ progress notes:
 Name and dosage of the medication
 Name of the practitioner who was notified of the error
 Time of the notification
 Nursing interventions or medical treatment
 Client’s response to treatment

Confidentiality
- The nurse is responsible for protecting the privacy and confidentiality of
client interactions, assessments, and care.
- The client’s significant others, insurance companies, or other parties not
directly involved in care provided by the health team may not have access to
clients’ records.
Methods of Documentation
 Narrative Charting
 Source-Oriented Charting
 Problem-Oriented Charting
 PIE Charting
 Focus Charting
 Charting by Exception (CBE)
 Computerized Documentation
 Case Management with Critical Paths

Narrative Charting
- Describes the client’s status, interventions and treatments, response to
treatments in story format.
- Now being replaced by other formats.
- Chronological
- Baseline charted Qshift
- Lengthy, time-consuming
- Source-oriented

Source-Oriented Charting
- Narrative recording by each member (source) of the health care team on
separate records.

Problem-Oriented Charting (POMR)

- Uses a structured, logical format called S.O.A.P.
 S: subjective data
 O: objective data
 A: assessment (conclusion stated in form of nursing diagnoses or client
problems)
 P: plan
- Uses flow sheets to record routine care.
- A discharge summary addresses each problem.
- SOAP entries are usually made at least every 24 hours on any unresolved
problem.
- SOAP was developed on a medical model.
Program Instruction in Health Assessment
- Nurses should achieve higher levels of education and training through an
improved education system that promotes seamless academic progression.
- The primary goals of nursing education are that nurses must be prepared to
meet diverse patients’ needs function as leaders and advance science that
benefits patients and the capacity of health professionals to deliver safe,
quality patient care
- Nursing education needs to be transformed in a number of ways to prepare
nursing graduates to work effectively and collaboratively with other
healthcare professionals in a complex and evolving health care system in a
variety of settings.

Program instruction
- Is a method of presenting new subject matters to students in a graded
sequence of controlled steps through a programmed material

Nursing Assessment
- Includes gathering information concerning the patient’s individual
physiological, psychological, sociological, and spiritual needs.
- It is the first step in the successful evaluation of a patient. Subjective and
objective data collection are an integral part of this process.

Teaching techniques
- Are the methodology and skills of an educator is using in the class.

Devices
- Are the equipment used while teaching.
- Examples: books, smart-board, tablets, computer, projector, or any device
that aids teaching

Advantages of programmed Instruction

- Main emphasis is on individual differences and student involvement
- Students may learn at their own pace
- Students are exposed only to correct responses limiting committing errors
- Student’s today are involved with online platform - activities that they can
do with mobile and other devices, and they are very much into this kind of
environment.
An Example of Health Assessment Instruction Tool is

Health Assessment Simulation tool

- This act as a single, simple solution to teaching health assessment
- Simulation based learning have 4 main purposes - education, assessment,
research, and healthcare system integration in facilitating patient safety

Simulation
- Is a term that refers to an artificial representative of a real-world process to
achieve educational goals through an experiential learning

Simulation-based learning activities

- Including use of standardized patients, role-playing exercises with peers, and
skills evaluations.

Assessment and evaluation of student learning and curricular effectiveness

- Assessment activities must be systematic, sequential, and ongoing, with
data collection and analyses used to improve student learning and attain
professional competencies

- Adaptive, interactive, virtual simulations with integrated curriculum

resources and personalized feedback provide a full simulation learning
experience for every student to promote competence and confidence in a
patient-centered care
- Simulation tools can track student progress and provide standardized
feedback that can aid in developing skills, they can also target skill
development-student can choose which skills to improve on and receive
specific training resources, and educators can also control the content

Fidelity
- Is the accuracy of the model or simulation when compared to the real
world.
Levels of Fidelity
Low Fidelity Simulation
- The simulations in this category will feel the least real to the learner. These
can include static models and two-dimensional displays. Goal: Increase
knowledge

Medium Fidelity Simulation

- These simulations are more realistic and allow more opportunities for
learning. Examples would be full body mannequins that mimic patients by
having breath sounds, bowel sounds, and heart sounds. Goal: Build
competence

High Fidelity Simulation

- These simulations are the most realistic and maximum interaction of
learners in an environment that closely resembles reality. These are full body
computerized mannequins that replicate the anatomy and physiology of a
real patient. Many of these manikins have the ability to talk, which allows
students to develop communication and problem-solving skills. High fidelity
manikins also have the capability to run pre-programmed scenarios. Goal:
Build performance and action

Types of Fidelity
Conceptual fidelity
- Ensures that the scenario makes sense. Is the lab work or medications
consistent with the signs and symptoms the patients are exhibiting? Subject
matter experts should be used to review sceneries to maximize conceptual
fidelity (Rudolph et al., 2007; Dieckmann et al., 2007).

Physical fidelity
- The degree to which the simulator duplicates the appearance and feel of the
real system (Alexander, Bruny©, Sidman, & Weil, 2005).
Emotional or Psychological fidelity
- Is the extent to which a simulation can duplicate or capture the real task by
using a simulated task and make the student feel as if it is real (Munshi,
Lababidi, & Alyousef, 2016).