Legal Implications (1)
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Legal Implications (1)

Perfect, this is exactly the level of detail I like. Let’s turn all of this into a clean Notion-style study guide with mnemonics, explanations, and organization – and I’ll build it so you can literally copy–paste into Notion as a full page.

I’ll divide it into 3 main pages/sections:

  1. Legal Implications – Fundamentals of Nursing
  2. Informatics & Documentation (HIPAA etc.)
  3. Patient Education (Chapter 25) – short but clear

🧠 LEGAL IMPLICATIONS – FUNDAMENTALS OF NURSING

(Requires memorization – organized + mnemonics)

🧩 1. Study Strategy for Legal Stuff

Tips for YOU (Braulio):

  • 🔍 For each law/concept, ask:
    • What does it protect?
    • How does it affect nursing actions?
    • How does it affect the patient?
  • 🧱 Base structure to memorize:
    • Sources of law
    • Patient rights (refuse, privacy, consent)
    • Torts (intentional, quasi-intentional, unintentional)
    • Delegation + scope of practice
    • Risk management, abandonment, documentation
  • 🧠 Mnemonic idea for sources of law – “CC ACC”
C C A C C
  • Constitutional
  • Civil
  • Administrative
  • Common
  • Case

Remember: “CC ACC – Laws that ACCtually control nursing.”

⚖️ 2. Sources of Law & How They Relate to Nursing (Learn with a table)

📜 2.1 Constitutional Law

  • Comes from the U.S. Constitution (federal + state).
  • Protects basic rights such as:
    • Right to refuse treatment (as long as patient is alert, oriented, has capacity).
  • Example:
    • A patient in the OR says: “I don’t want the procedure anymore.”

      • 👉 The procedure must be stopped, even if consent was already signed.

🧾 2.2 Civil Law

  • Defines nursing practice and standards of care at the state level.
  • Includes Nurse Practice Act:
    • What nurses can and cannot do.
    • Example: “You cannot intubate a patient” as an RN.
  • Used when a patient sues for malpractice.

🏛️ 2.3 Administrative Law

  • Created by state boards of nursing and agencies.
  • Controls:
    • Licensure
    • Disciplinary actions
    • Rules for nursing practice

You can lose your license before even getting it if you violate laws (e.g., big HIPAA breaches, fraud).

👥 2.4 Common Law

  • Based on previous court decisions (“case law”).
  • Includes:
    • Right to privacy → relates to HIPAA.
    • Standards determined by:

      • 👉 “What would a reasonably prudent nurse do in this situation?”

📚 2.5 Case Law

  • Specific legal cases that went to court.
  • Used to define:
    • What is negligence?
    • What counts as malpractice?
    • What kind of documentation is legally acceptable?

🫱‍🫲 3. Patient Rights, Access, & Refusal

🏥 3.1 Duty to Treat

  • Institutions cannot refuse emergency care just because:
    • Patient has no insurance
    • Patient is poor or undocumented
  • Private institutions cannot say:

    • “Go to the public hospital.”

    But they can say:

    “This service is not available here”

    and provide basic stabilizing care and then arrange transfer.

🚪 3.2 Right to Leave – No False Imprisonment

  • If a patient is alert, oriented, has capacity, and says:
    • “I want to leave.”

    → You must let them leave.

  • If they refuse to sign the AMA form:
    • Two nurses can sign as witnesses.
    • That protects you from false imprisonment claims.

💬 3.3 Consent, Assault, Battery

  • Assault = Threat of harm, no physical contact.
    • “If you don’t take this med, I’ll tie you down.” → Assault.
  • Battery = Touching without consent. (Think battery like electricity, you touch to transmit electricity)
    • Giving an injection the patient refused.
    • Applying restraints without order and without danger → Battery.
  • If pt says, “I don’t want this” and you still do it → Assault + Battery.
  • If pt says, “I don’t want this” and you still do it → Assault + Battery.

🧠 4. Organ Donation & Brain Death

  • Age ≥ 18 → can be an organ donor (often noted on driver’s license).
  • Two physicians must determine brain death.
  • Tests may include:
    • Caloric stimulation → checks vestibular system + brainstem
    • Blood flow studies → imaging to see if there is cerebral blood flow
  • Family usually given 24–48 hours to process situation.
  • If patient is a donor → organ procurement team gets involved.
  • If Glasgow Coma Scale < 8:

    • 🎱

  • The hospital notifies the organ procurement organization to evaluate possibilities.

🧑‍⚖️ 5. Torts – MUST KNOW FOR FINAL + NCLEX

Tort = A civil wrong against a person or property.

🟥 5.1 Intentional Torts

  1. Assault
    • Threat of harm. No contact needed.
  2. Battery
    • Intentional touching without consent.
    • Ex: Giving a med or starting IV if patient refused.
  3. False Imprisonment
    • Keeping a patient somewhere against their will.
    • Example:
      • Telling a patient, “You can’t leave” when they are competent.
      • Locking bedrails/restraints without reason or order.
⚠️ If the patient is a danger to self or others and you have a valid order → restraint is not battery or false imprisonment.

🟧 5.2 Quasi-Intentional Torts

  1. Defamation of Character
    • Damaging someone’s reputation with false statements.
    • Slander = spoken
      • Ex: Saying a patient “looks like they have gonorrhea” without any proof.
    • Libel = written
      • Ex: Writing false statements about the patient in the chart.
  2. HIPAA-related Defamation
    • Posting about patients on social media → can be defamation + HIPAA violation.

🟨 5.3 Unintentional Torts

  • Negligence
    • Failure to act as a reasonably prudent person would.
  • Malpractice (Professional Negligence)
    • Negligence by a professional (nurse, doctor).
    • 4 elements:
      1. Duty
      2. Breach of duty
      3. Harm
      4. Causation
  • Example:
    • Leaving a high fall-risk patient in high bed position, no rails, no call bell → patient falls and dies.

      • → Negligence/malpractice.

🧑‍⚕️ 6. Delegation, Scope, Abandonment

🧬 6.1 Scope of Practice & Delegation

  • Know what you can delegate to:
    • AP/CNA → vital signs, hygiene, ambulation, basic tasks.
    • LPN/LVN:
      • Can give some meds (depending on state).
      • Can collect data and reassess stable patients.
      • In most states: cannot perform initial comprehensive assessment or make nursing diagnoses.

        • 👉 RN is responsible for initial assessment and care plan.

Before you delegate, you must know their scope.

🧍‍♀️ 6.2 Patient Abandonment

  • You can refuse an assignment, but:
    • Do it before you accept it / clock in or receive report.
  • Once you accepted the assignment → you are responsible for the patient.
  • Instead of:

    • “I don’t want this patient.”

    Say:

    “This assignment feels like unsafe practice because… (explain reason).”

🧑‍⚖️ 6.3 Assisted Suicide (Euthanasia)

image
  • Nurses do not participate in assisted suicide.
  • Depending on state laws, even in “death with dignity” states, nurses’ role is limited and controlled.

🛡️ 7. Risk Management, Depositions, & Standard of Proof

⚖️ Standard of Proof (This is like the ideal of “What you should have done”

  • Question in court:

    • “What would a reasonably prudent nurse have done in this situation?”

  • This is based on:
    • Policies
    • Standards of practice
    • Documentation

🧾 Risk Management

  • If something happens that could harm patient → call Risk Management:
    • E.g., patient falls and you forgot to put fall precautions → call them.
    • They help investigate and prevent future events.

📚 Depositions & Legal Process

  • If family sues hospital:
    • Lawyers will take depositions (formal questioning).
    • Hospital lawyer will ask:
      • What did you do?
      • Why did you do it?
    • You often must review your notes to remember.
If it’s not documented, legally it is assumed not done.

🖥️ INFORMATICS & DOCUMENTATION

📓 1. Core Principles

  • “If you didn’t document it, you didn’t do it.”
  • Documentation is:
    • Legal record
    • Communication tool
    • Basis for billing & reimbursement
    • Evidence in court
  • Use the Nursing Process when documenting:
    • Assessment
    • Diagnosis
    • Planning
    • Implementation
    • Evaluation
  • Patient teaching

🧾 2. Incident Reports

  • Do NOT chart “incident report filled” in the patient chart. Charts are legal document public to any investigation.
    • Incident report is an internal hospital document.
    • Lawyers can access it if you mention it in chart.
  • Example:
    • Chart what happened factually:
      • “Pt found on floor lying on right side, alert, denies pain…”
    • Separately: fill an incident report for hospital risk management.

🔐 3. HIPAA & Confidentiality – What You MUST NOT Do

Use this in Notion as its own section. 👇

✅ NURSING — THINGS YOU MUST NOT DO WITH PATIENT INFORMATION

❌ 1) Do NOT print or keep PHI unsecured

  • Don’t leave printed records on desk.
  • Don’t throw PHI in regular trash → must be shredded.
  • Don’t keep printed notes after shift.
  • Don’t take printed charts home.
If you print → Secure it and destroy it properly.

❌ 2) Do NOT share information with unauthorized people

  • Don’t share with family unless patient allows it.
  • Don’t share with coworkers who are not involved in care.
  • Don’t share in hallways, elevators, cafeteria.

❌ 3) Do NOT look up charts “just because”

  • No “curiosity” chart reviews, even if it’s your friend/family.
  • Only look at patients you are actually caring for.
System logs all access → curiosity = violation.

❌ 4) Do NOT discuss PHI in public areas

  • No patient talk in:
    • Elevator
    • Cafeteria
    • Shuttle / parking lot
    • Waiting room

❌ 5) Do NOT leave computers unlocked

  • Always log out before leaving.
  • Don’t share passwords.
  • Don’t write passwords on sticky notes.

❌ 6) Do NOT text or take photos with your personal phone

  • No photographing wounds, faces, charts on personal devices.
  • No texting patient info over normal SMS/WhatsApp.
  • Only use approved secure systems.

❌ 7) Do NOT post anything about patients online

  • No TikTok, Instagram, Facebook, Snapchat stories.
  • Even if you don’t say name → still risk.
  • No “crazy patient story” posts.

❌ 8) Do NOT leave PHI visible

  • Don’t leave paper charts where family or visitors can see.
  • Don’t leave printed report sheets at nurse station when off shift.

❌ 9) Do NOT gossip about patients

  • Don’t talk about cases with friends/family at home.
  • Don’t discuss other units’ patients if not part of their care.

❌ 10) Do NOT fax/email without verifying

  • Check fax number + use cover sheet.
  • Use only secure email channels approved by hospital.

🔑 PHI (Protected Health Information) Includes:

  • Name, address, date of birth
  • Room number
  • Diagnosis, test results
  • Images, videos
  • Billing info
If it can identify the patient → it’s PHI.

🚨 Consequences of HIPAA Violation

  • Write-up / discipline.
  • Fired.
  • Board of Nursing investigation.
  • Fines, lawsuits.
  • Possible loss of license in serious cases.

💻 4. Other Informatics & Documentation Points

  • Always log out of the computer when done.
  • If a fax with PHI goes to the wrong number → patient must be notified per policy.
  • If you print anything, destroy it after use (shredder).
  • Document every phone call with provider:
    • Time
    • Who you spoke with
    • What they said
    • Any new orders
  • Acuity rating systems:
    • Used to see how sick the patient is.
    • Helps with staffing decisions.
  • Nursing Informatics “Superusers”:
    • Nurses trained to help others use the electronic systems.
    • They teach how to document, use new functions, etc.

🏥 Length of Stay & Documentation

Your example:

Pt has pneumonia, aspirates in hospital, develops cardiac issues, length of stay increases.

How to think about it:

  • You must clearly document:
    • Initial diagnosis: pneumonia.
    • New event: aspiration.
    • New complication: cardiac problems.
  • This documentation:
    • Justifies extended length of stay.
    • Affects billing, reimbursement, and quality measures.
  • The system often needs a new diagnosis/complication added so insurance doesn’t deny extra days.

📚 PATIENT EDUCATION (CHAPTER 25)

🎯 Purpose of Patient Education

  • Maintain health
  • Restore health
  • Promote coping with chronic conditions

Nurse’s role:

  • Determine what the patient needs to know.
  • Assess readiness to learn.
  • Choose teaching strategies appropriate to their level.

🧠 Domains of Learning (MUST KNOW)

  1. Cognitive – thinking / understanding
    • Lectures, reading, explanations.
    • Ex: Pt explains back what diabetes is.
  2. Affective – feelings, attitudes, values
    • This is the hardest because it involves emotions.
    • Ex: Pt accepting the need for lifestyle changes.
  3. Psychomotor – hands-on skills
    • Ex: Pt demonstrates how to inject insulin.

🟢 Readiness to Learn (Explained Better)

Readiness to learn = patient is:

  • Physically able (not in severe pain, not heavily sedated)
  • Emotionally ready (not too anxious, angry, or in shock)
  • Sees a reason to learn (understands “what’s in it for me”).

Example:

  • Diabetic pt who doesn’t believe they’re sick → not ready to learn.
  • Once they realize high sugar can lead to amputation → motivation rises → now more ready.

✏️ Always Document Teaching

  • Always include in chart:
    • What you taught (content)
    • How (method – demo, pamphlet, video)
    • Patient’s response (verbalized understanding, demo skill)
  • Example:
    • “Taught pt to avoid walking barefoot due to risk of foot injury. Pt verbalized understanding and repeated back instruction.”

If you want, next step I can:

  • Turn Legal Implications into a pure Q&A deck (like “Ask me questions randomly”).
  • Make 10–20 NCLEX-style questions just on torts + HIPAA so you can test yourself.