Legal Issues & Documentation Flashcards
(31 cards)
Negligence
unintentional
fail to meet standards of care
foreseeability of harm
omission/commission of an act
damages
Defendant
object of lawsuit
Doctrine of personal liability
responsible for own actions
Doctrine of foreseeability
to see harm will happen from acts or omissions of acts
Types of law
statutory - made by legislation
common - based on court decision
Tort
wrong committed by one person against another
Subpoena
court order to appear to testify or bring something
Deposition
statement given
Perjury
false testimony
Doctrine of respondent superior
employer liable for employee
Doctrine of borrowed servant
captain of the ship rule
surgeon gave order - is liable
Defamation
speaking ill of a patient, staff, or physician
Plaintiff
person bringing lawsuit
Advance directive
not in will
Civil assault/battery
threat to harm physically
carrying out bodily harm/touching without consent
Consent forms
surgical
anesthesia
admission
How to ID patient’s documentation
ID sticker on all surfaces
Failed equipment
tell someone, remove from room
collect everything
Damages
loss cause of items
Malpractice
professional misconduct
duty
deviation
damage
direct cause
AST code of ethics
1985 guidelines for ST
Scope of practice
education, experience, credentials
Intraoperative record
done by circulator
always a legal document
Legal elements of documentation
standard terminology
spelling
facts
legible
correction of errors
legal sig of reporter
