Nursing Documentation In Nursing

This type of disclosure is an organizational violation, but could also lead to legal ramifications as well. Incidental disclosure of protected health information is not considered to be a “violation of the HIPAA medical privacy regulation provided the covered entity has applied reasonable safeguards” (Hatton, 2003) to help prevent them. This error also has the potential to cause distrust in the patient that the nurse is transporting, causing them to lose faith in the company. The nurse stopped Sue in the hallway (a public space), while transporting another patient, to tell Sue that there was an issue. The nurse made no attempt to keep the issue private and rattled of the details in front of the escorted patient, even though the situation was not an emergency or life threatening.

Paternalism, this article elaborated on advocacy as the main drive to health care decisions. The patient is the core of focus when we make health care decisions at all levels. “Advocacy is the center of nursing care” (Zomorodi and Foley, 2009, p.1748). We have to stand out for our patient at every circumstance to see that they are well cared for during hospital visit when they get home after discharge and when we make health care policies to cover them. The article also express paternalism as Zomorodi and Foley (2009) explained paternalism a decision take to denied patients of certain right base on their health situation.

Clinical examinations offer significant chances for nurses to identify a suitable therapy association with their clients. Hence, the examination is seen as both interpersonal and intellect based activity. Assessments of sick people involve several steps. Screening examination helps gather necessary facts, analyses them and later group them into useful information. Potential analyses combine all possible examinations that associate with available information about a patient.

Given the pros and cons of rational decision-making, the healthcare environment may not be the best fit for the willful choice model. Within healthcare organizations, chaos is prevalent with little time to thoroughly analyze a problem and produce

I think this policy falls short of its goals and objective, which is to protect the patient. The ultimate goal is for the patient to receive safe, quality, affordable care. To ensure effective and efficient care Congress, CMS and all stakeholders involved will need to review, address and revise the issues and concerns surrounding this policy to prevent undue harm to the

State-mandated nurse-to-patient ratios remains a controversial topic in healthcare. Sufficient nurse staffing is key to ensure adequate patient care, while scarce staffing effects patients’ safety and puts nurses at risk for burnout. Determining nurse-to-patient ratios in nursing facilities remains a challenge for the nursing profession. There are many factors to consider when determining staffing methods, such as cost, nurses’ satisfaction, patient outcomes and safety. Mandating ratios is one attempt at ensuring nurses’ workloads do not exceed what is needed for adequate patient care and safety.

But painful scenario like this where patient cannot make decision. They would have filled substitute decision making document that allows capacitated patient to appoint a person on his or her place in making healthcare decision if the patient become incapacitated. Depending upon the state law designation may take proxy form, surrogate power of attorney, health care agent and allows physician to constant the decision with surrogate and implement the treatment decision (Johnson,

According to Kant nurses must determine if lying is an acceptable ethical behavior. Rationally, lying is not ethical and is not tolerable to any situation as it violates the duty to tell the truth to those individuals who are entitled to honest information, in which nurse-patient relationship or trusts will not develop. Deontologist also believes that killing a fetus is wrong and immoral. Deontology suggest that health care workers have a ? moral duty, to maintain and preserve life?

. Informatics working within a healthcare facility may be involved in selecting and evaluating technology; determining consumer/end-user requirements, customizing functionality, and designing and delivering training. In addition to working in hospitals, informatics nurses can also be found a variety of healthcare setting including home/hospice care, acute care specialty clinics, public health departments, academic medical centers, and policy and standard organizations, among others. According to Baker (2012), the key responsibilities of nursing informatics include: analyzing clinical and financial data; delivering nursing content into standardized languages; endorsing and facilitating research and reference access; improving continuity of care;

Consent is one of the key principles that guides health care professionals in the NHS constitution, this reflect the needs and preference of patients, their families and carers where right decision will be made and will be informed on all decision of their care and treatment, (DH ,2012), however healthcare professionals need to share information with the family and carer with the patient consent, and ensure a confidentiality policy is in place and followed by all staff (DH, 2003). It was important to explain to Mary-Jane of her need to be in the chair as it was a part of her ongoing treatment which was put in by the physio-therapist, as it was Mary-Jane right to accept or refuse this part of her treatment, (DH ,2012). In keeping with (NMC, 2013) code the student nurse gaining consent before taking Mary-Jane out the bed had to fully respect her right to decline or to accept as long as she fully understand what was said to her (Mental Capacity Act, 2005) as this shows that the patient decision was been respected. This indicates that the client is being protected

It is extremely important that every patient has the opportunity to control the care they wish to receive in case of medical emergencies. These wishes may be addressed through legal documentation, known as advanced directives. Through the use of advanced directives patients can appoint a healthcare proxy, express their living will, and make decisions about hospice and palliative care. Advanced directives allow patients to make decisions that may be hard for their families, and their providers to make during this difficult time. “A living will spells out what types of medical treatment a person wants at the end of life if he’s unable to speak for himself ("Power of Attorney, Living Will, and Advance Directive - AARP").”

The article stated that business associates can offer DDE as an option to health plans and also DDE can be customized as well. Since DDE is an option, health plans can offer DDE to certain providers but DDE system must meet the requirements of HIPAA because of the information that is transmitted via electronic. However, some critical issues involved were sending as a transaction which is not DDE and health care plans are not to offer incentives to use the DDE system. Also, electronic data interchange (EDI) could not replace DDE because it is an option to providers but EDI has to used (Nachimsom,

Complaints. If you believe that your privacy rights have been violated you may file a complaint with us or the Secretary of Health and Human Services. All complaints must be in writing. b. If it endangers the patient 's life or physical activity the request can be denied.

There are three implications that would occur if a change in law were past, one would be the change in palliative care. Adequate palliative care is a prerequisite to the legalization of medical aid in dying. Patients should never have to choose death because of unbearable pain, which can be treated but cannot be accessed. It is wrong to deny grievously ill patients the option of medical aid in dying because of systematic inadequacies in the delivery of palliative care. Safeguarding patients by building a strong patient physician relationship must be established so that there is no foul play in the outcome.

*Use and disclosures: We use and disclose health information for many different reasons. For some of these uses or disclosures, we need your prior specific authorization such as: • uses and Disclosures Relating to Treatment, • to obtain payment for treatment, • for health care operations such as evaluating the quality of health care services that received or evaluate the performance of the health care professionals. • providing patient PHI to our accountants, attorneys, and consultants who perform services on behalf of our patients. Other Uses and Disclosures That Do Not Require Your Authorization are: • Disclosures required by federal, state or local law, judicial or administrative proceedings, or law enforcement such as information about victims of abuse, neglect or domestic