Legal & Documentation Terms

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Across
  1. 2. examples include administering an injection after patient refusal or pushing a patient into a chair
  2. 4. Practice Act, legally defines the scope of practice for each state
  3. 7. ex: a nurse documents vital signs on a patient that they did not actually obtain
  4. 11. event, unexpected occurrence resulting in death or serious injury to a patient
  5. 12. refers to ways in which professional competence is ensured and maintained
  6. 14. failing to round on a patient for 10 hours straight during a 12-hour shift
  7. 15. the process by which an educational program is evaluated and recognized as having met certain standards
  8. 18. examples include not reporting critical lab values to the provider or not using proper safety equipment to transfer a patient (and they fall)
  9. 20. notes, notes written to inform caregivers of the progress a patient is making
  10. 21. the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area
  11. 22. law that ensures patients can request updates or corrections of mistakes to their health records
Down
  1. 1. back, when a nurse receives a verbal or telephone order and the nurse repeats the order back to the provider
  2. 2. report, a type of change-of-shift handoff which takes place in the patient's room
  3. 3. an example would be threatening to restrain a patient for not staying in their chair at lunch
  4. 4. notes, notes that address routine care, patient data, and patient problems identified
  5. 5. spoken defamation of character
  6. 6. by exception, a common type of documentation in which only significant findings to predefined norms are documented in detail
  7. 8. written defamation of character
  8. 9. directives, examples include living wills and a having a healthcare power of attorney
  9. 10. abbreviation given when a patient does not wish to be resuscitated
  10. 11. a type of note that addresses subjective data, objective data, an assessment, and a plan
  11. 13. Samaritan law, protects health care providers when giving aid in emergency situations
  12. 16. report, these are used by hospitals for quality improvement after patient falls, needle sticks, etc.
  13. 17. imprisonment, unjustifiable detention of person without legal warrant to confine the person
  14. 19. intentional or unintentional acts of wrongdoing