Legal, ethical and professional issues Flashcards
Duty of care duty of Candour clinical documentation
What is duty of care
Duty of care is a civil law concept within the uk and exist to ensure that one party does not allow unreasonable harm or loss to occur to another Dimond2011
as a health care professional, you owe a duty of care to your patient from the point at which they are accepted as a service user HCPC 2012
from that point onwards you must at in a way to prevent harm where reasonable person could see that harm might occur
What is duty of candour
Duty of candour is a legal obligation on healthcare providers to inform a patient if they have been harm. this means in simple terms being honest and admitting if you have made a mistake and reporting it openly and honestly.
Documentation importants
Get into the habit of using factual, consistent, accurate, objective and unambiguous patient information;
Use your senses to record what you did, such as ‘I heard’, ‘felt’, ‘saw’, and so on;
Use quotation marks where necessary, such as when you are recording what has been said to you;
Ensure there is a reasoned rationale (evidence) for any decision recorded, for example, denying access to a visit from children;
Ensure notes are accurately dated, timed, and signed, with the name printed alongside the entry (initials should be avoided);
Follow the SMART model (Specific, Measurable, Achievable, Realistic and Time-based) or similar when planning care;
Write up notes as soon as possible after an event and, by law, within 24 hours, making clear any subsequent alterations or additions;
Document any objections you may have to the care that has been given;
Do not include jargon, meaningless phrases (for example ‘slept well’), irrelevant speculation, and offensive subjective statements;
Write the notes, where possible, with the involvement and understanding of the patient or carer (NMC, 2002c).
mental capacity act
gaining valid consent
in order to gain valid consent three criteria must be met
- consent must be given freely
- consent must be informed, the patient must understand what is going to happen
- the patient needs to have the mental capacity to do so
communicating consent
- verbally
- writen
- sign language
- bliking
- movement of limbs
mental capacity can be either
two things
Temporary
postictal
hypo
alcohol
drugs
or
Permanent
dementia
long term brain damage
assessing capacity
two stage test
- does the patient have an impairment
- does that impairment stop them from make own dicisions
negligence
Negligence occurs when duty of care is breached and foreseeable harm occures.
there are four stages for negligence to be proven
- establish duty of care
- breach of duty
- harm occurred
- caustion
what is Consent
in the uk case law has determined the adult patients with capacity must give consent before they are touched or treated, failure to do so leaves crew open to civil clams dimond 2008
Valid consent
in order for consent to be valid
- consent must be given voluntarily with out pressure
- consent must be informed. pt must understand what course of action is being proposed any risks, consequences of not having treatment, any alternatives
- the person consenting needs to have the mental capcaity to do so
communicating consent
written
verbal
non verbal
other
sign language
blinking
capacity
two things
Temporary
permanent
The dignity pledge
- Respect colleagues, service users and the public’s individuality and freedom of choice
- Encourage and support each person in their own independence
- Support our patients, the public and colleagues to enable them to communicate and understand each other’s needs
- Provide privacy and dignity during all interaction with our service
- Engage with our service users and colleagues to ensure they are informed and involved
- Challenge poor practice and have zero tolerance of abuse
- Take accountability and reflect on our own actions to improve our practice
4 things
Atitudes Privacy
Behaviours Dignity
Law Values
Ethics beliefs
