Nurse Practice Act
You can obtain ac copy of the Nurse Practice Act from your State Board of Nursing. This is the standard that will be used if a malpractice suite is filed. Become familiar with the acts and duties in your area of practice. These will vary from state to state.
Policy and Procedure Manuals
Become familiar with the general nursing manual as well as any that pertain to your specific area of practice. If your hospitals policy differs from the Nurse Practice Act, follow the guidelines of the Nurse Practice Act. Note: if there is ever a negative outcome, the licensed nurse will be judged by the standard of the Nurse Practice Act.
Insurance
There are two types of insurance:
Occurrence Type: The company that covered you during the period of the occurrence will be responsible for damage and expenses.
Claims Type: The company will cover any claims made while the policy is in effect, no matter when the occurrence happened.
Education
Continuing education is a necessity. It keeps you informed of the most current changes and innovations in your specialty area, it is an area that attorneys will investigate if a claim is filed.
License and certification must remain current at all times. This is another area that attorneys will investigate if a claim is filed.
Terms to Become Familiar With
Negligence: failure to act as a reasonably prudent person would act under the same circumstances failure to do something.
Malpractice: negligence by a professional.
Assault: threat or attempt to inflict bodily harm combined with the ability to commit the act.
Battery: intentional harmful or offensive contact that occurs without consent (use of restraints with out an order or a written policy of protocol).
Libel: publication of defamatory statements.
Slander: oral defamatory statements
Statute of Limitations: there are periods defined by state statute during which you may file a claim or it is forever barred.
Informed Consent: Permission given for a proposed treatment or procedure following full disclosure of risks, benefits and alternatives by the physician when you are asked to sign your name as a witness on the consent from. Remember you are a witness to the patients signature only.
Physician Orders:
Telephone Orders: Repeat each order t verify what you heard is what was ordered. Never assume.
Illegible Orders: Ask the physician for the interpretation. Do not guess.
Inappropriate Orders: Remind the physician of the policy and standards. If the physician insists that the order be completed, contact he supervisor immediately
Documentation Tips and Practices:
Be accurate
Use only approved abbreviations (found in the Policy and Procedures Manual).
If you make a mistake, draw a single line through it and write mistake in entry followed by your initials.
Document calls to doctors. Record the time the call was placed as well as when the call was returned.
Document all teaching done with the patient and the patients family.
Document the review of discharge instructions including the review of any medications prescribed and any handouts provided.
Record effects of medications as well as the des, time, route and reactions.
If anything out of the ordinary occurs, record all pertinent information.
If you perform a procedure on a patient assigned t another nurse, you must document your actions in the patients chart.