Question

Identify and outline 2 (two) legal requirements you must apply when writing nursing reports.

Answer 1

Nursing documentation provides information about client it's required by both accreditation,reimbursement agencies and state,federal governments..Proper documentation need accurate nursing diagnosis and nursing process..It includes doctor's order,medicine administration.vital signs and admission procedure.. HIPAA Outlines for Privacy rights for individual regarding health information..
Legal requirements for nursing chart:-
   Accurate Nursing reports are most important for medical records..charting the documents correctly will prevent the legal issues and it will protect both nurses and patient..If the nurse has administer the medication but they forget to chart a medication there will be legal action..Nurses carelessness for not administering the medication but there is a order in the chart..Medical errors and false documentation has serious legal consequences..
      charting in advance also never acceptable it can make some errors..Timely charting is important..Routine care for every 1-2 hours should be done..Medication and other emergency procedure must be documented immediately an also writing should be neat and legible in black or blue pin not by pencil..If errors occured that cannot be erased or strick out..In that place error should be indicated by making a line through the text and write 'Error'.Important documentation must be in correct forms.Physicians telephone order must be documented like 'T.O' and verbal order 'V.O'..Timing should be noted as AM or PM..client name and identification number must be same in all pages and in investigation chart..Before administering medicine allergy should be checked and must be documented according to the hospital policy.
   Never use non-standard terms for documentation..This is a legal documents to use proper english and grammar to prevent misinterpretation..Late entries should be documented by date and time by following 'Late entry'..
Medication/Treatment errors:-
   There are more legal issues for documenting medication administration..wrong drug and its doses have a serious consequences for both patient and nurses..If patient have side effects or toxicity because of this overdose of medication the patient will be harmed that time there will be legal action for nurses..It is nurses responsibility to see the allergy before administring medication...before giving medication 5 rights should be followed(Right time,right patient,Right dose,right medication,right route) should be followed..After administering medicine date and time,Name of medication,dosage order everything must be documented correctly and how patient reacts after the medication also should be there to avoid medical nd legal errors and to provide sae environment for the patient...