Suicide and Documentation: Don’t Let the Pen Kill Your Career

1. Nurses' notes must reflect the assessment performed regarding their patients' risk factors, red flags, and protective supports, especially for suicidal patients. 2. Nursing interventions range from the least-restrictive methods to full restraints, if necessary to prevent patients from harming themselves. 3. Medications, such as antidepressant, antipsychotic, and antimanic agents, as well as benzodiazepines, have been shown to help psychiatric patients cope with depression, psychosis, and mood stability.

Try a mock trial

In today s litigious climate, it is important for nurses to understand what constitutes malpractice. This knowledge can help them avoid a lawsuit, a process that can be physically, emotionally, and financially draining. It can also guide their practice so that they provide better care for their clients. The elements of malpractice can be taught through the use of a mock trial. A mock trial can be incorporated into any nursing class and is a valuable educational tool in helping students understand both the legal system and how their practice is viewed. The nurse attorney author discusses a mock trial scenario that can be used to impart information and teach the critical thinking skills necessary for successful nursing practice.

In pursuit of justice. Interview by Lynne Wallis

Andrew Scott is a nurse turned barrister who uses his paediatric experience to defend parents accused of harming or killing their children.

The importance of keeping patient records secure and confidential

The NMC state that, ‘good record keeping is an integral part of nursing and specialist community public health nursing practice. It is a tool of professional practice and one that should help the care process. It is not separate from this process and it is not an optional extra to be fitted in if circumstances allow.’ (NMC, 2005)

Wound Documentation: Managing Risk

PURPOSE

To provide the physician and registered professional nurse with an understanding of consistent wound documentation and the potential for legal issues to arise.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in better understanding and improving policies and procedures related to wound documentation.

OBJECTIVES

After reading the article and taking the test, the participant should be able to: 1. Discuss wound assessment and documentation relative to current practices and potential legal implications. 2. Describe recommendations to improve the consistency and accuracy of wound assessment and documentation.

Making decisions for incapable adults 1: Capacity and best interest

The Mental Capacity Act 2005 is expected to come into force in April 2007. It will change the way decisions are made for incapable adults in England and Wales. District nurses, along with other health professionals, will be required to abide by the provisions of the Act when providing care and treatment to incapable adults. In a short series of articles, case studies will be used to illustrate how the new law will affect district nurse practice, beginning with the assessment of capacity and best interests. District nurse Mary Holt regularly visits a patient, 78-year-old Jane Harris, in her home to treat a chronic leg ulcer. Jane has been diagnosed with Alzheimer's dementia but is managing well with support from the local authority. However, Mary has noticed recently that Jane's behaviour has become a little strange. She looks unkempt and she is continually washing dishes that are not dirty. On her last visit, Jane refused to allow Mary to remove the dressing on her leg and treat the ulcer, which has become infected. Mary is concerned that Jane's wound needs to be treated to prevent further complications.

Prescription and medication records

All nurses are required to keep contemporaneous records which are unambiguous and legible. The NMC has reprinted the UKCC guidelines for records and record keeping (UKCC, 1998). The Department of Health has provided advice in its guidance on the implementation of independent nurse prescribing on the standards for prescription writing (DH, 2002).

Midwifery Records and legal issues surrounding them

Midwives are subject to statutory supervision and the Midwives' Rules. The Nursing and Midwifery Council has set out very special and very strict rules on how midwives records should be kept, stored, handled and supervised. Rule 9 sets out stipulations in relation to the keeping of midwifery records. Rule 10 requires them to permit the inspection of their records by the supervisor, the local supervising authority and the NMC.

Medicare and Medicaid programs; requirements for long term care facilities; nursing services; posting of nurse staffing information. Final rule

In this rule, we finalize provisions specified in the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) that establish new data collection, posting, and recordkeeping requirements for skilled nursing facilities (SNFs) and nursing facilities (NFs). It requires that on a daily basis for each shift, SNFs and NFs must post nurse staffing data for the licensed and unlicensed staff directly responsible for resident care in the facility. Facility census information must also be posted. This final rule is also part of a broader communication outreach initiative by CMS to provide beneficiaries, their families, and the public with access to updated data and other information that can assist them in making healthcare decisions.

Exploring the legal status of healthcare documentation in the UK

This article considers the legal status of documentation and the point at which records become legal documents. It outlines the powers of the courts that require any documentation or other records to be produced if relevant to an issue arising in a dispute. It also discusses hearsay evidence and the fact that usually evidence on records needs to be corroborated.

Is your statement writing up to scratch?

Patients now have a willingness to litigate when things go wrong with their care. One day you may have to write a statement for the purpose of forming a defence in a clinical negligence claim. A well written statement can be an excellent defence against allegations. John Beesley, AfPP's Lead Professional Officer, outlines guidance and best practice for statement writing.