5.2 Standards of Care in Nursing

Question 1

Standard of Care

Answer 1

• Involves what actions a reasonable/prudent nurse would do in a similar circumstance
• Nurse Practice Act (NPA) passed by Board of Nursing (BON)
• Standards of Practice (ANA)
• Patient’s Bill of Rights
• Hospital Policies
• Previous Court Rulings

Question 2

When to Question Doctor Orders

Answer 2

• If the patient questions it
• If the patient’s condition has changed
• Read back orders to doctor if it is a verbal order
• If the order is illegible or incomplete

Question 3

Documentation

Answer 3

• Always done as soon as possible
• Late entries should be labeled as late
• Must include all assessments, interventions, client responses, instructions, and referrals in the medical record.

Question 4

Incident and Quality Assurance Reports

Answer 4

• Patient name
• Factual account of incident
• Pertinent characteristics of the patient
• Important variables that may have impacted the incident
• Documentation of an examination by the physician

Question 5

Avoiding Litigation

Answer 5

• Document assessments, interventions, and evaluations fully. Timely completion of documents is your best defense
• Develop a caring rapport with your patient and family while observing professional boundaries
• Communicate with other health care providers in a clear, respectful manner and expect the same from them
• Be aware of potential sources of injuries (falls, med errors, and name errors)
• Communicate with patients and explain procedures
• Report and document changes in patient condition.