Institute: ONC | Component: 2 | Unit: 6 | Lecture: b | Slide: 19
Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Nursing Care Processes
Lecture:Nursing process including clinical judgment and patient assessment; legal and societal expectations; and roles in improving patient care
Slide content:Legal Issues: Documentation, Dosing, and Reporting Nurses must document all care provided Nurses must administer medications correctly Right drug Right patient Right dose Right time Right route (oral, rectal, injection, etc.) Nurses must report any abuse allegations to authorities 19
Slide notes:Nurses also need to adequately document all the care that they give to a patient. This documentation creates a legal record, so it needs to be clear, objective, and thorough. Medication errors cause hundreds of thousands of deaths and injuries in the United States every year, and nurses and their employers can be held liable. Nurses are expected to give the right drug to the right patient, at the right dose, at the right time, and by the right route. If a patient shares that he or she, or that someone else, was abused, nurses are legally obligated to report this information to the appropriate authorities. For example, a patient might make an allegation of domestic abuse, child abuse, or sexual abuse. 19