Legal Aspects of Nursing

Values, Ethics & Advocacy

Noor Aini Hussain

PPSK

11/25/2012

Consider
What does it mean to be
professional ?

What does it mean to be a

professional?

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IPPT Kursus Pemantapan Klinikal

Professionalism in Nursing
A template to assist nurses with
the complexities of daily practice.

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What is Professionalism?
Knowledge (based
on scientific
principles)

Well-developed group
consciousness

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Intellectual and
individual
responsibility

Specialization

Attributes of Nursing Professionalism

Collegiality and
Collaboration

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Ethics
and
Values

Autonomy

Establishing a professional role is a

prerequisite for establishing control over
practice.

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IPPT Kursus Pemantapan Klinikal

Accountability
Definition:
Responsibility for ones conduct or the
willingness to be answerable for ones
actions.
(Concise Oxford Dictionary, 1982; Bergman, 1981)

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Autonomy
Definition:
Right of self-government; personal freedom.
Concise Oxford Dictionary, 1982

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Advocacy
Definition:
An advocate is a person who supports or speaks out
for a cause, policy.
(Concise Oxford Dictionary, 1982)
This includes being an advocate/change agent for
clients, families and communities as well as the
profession.
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Advocacy
Nurses should have input into all aspects of
patient care within their scope of practice
including serving as patient advocates
An advocate supports or speaks out for a
cause, or policy. Includes being a change agent
for clients, families, communities and the
profession.
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Ethics & Values

Definition:
A system of valued behaviors and beliefs for
determining right or wrong and for making
judgments about what should be done to or for
other human beings.
Nursing ethics is reasoned reflection and enquiry
about the ethical dimensions of nursing practice
as it impacts on the lives of patients, colleagues
and society.
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Professionalism and Ethics

means.
Having knowledge about
ethical values, concepts
and ethical decisionmaking.
Being able to identify
ethical concerns, issues
and dilemmas.
Applying knowledge of
nursing ethics to make
decisions and to act on
decisions.

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Nursing Considerations
To fully appreciate
and incorporate legal
and ethics principles
into individual
nurses practices

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As nursing professional has continued

to evolve, the scope of applicable law
has enlarged considerably.

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DOCUMENTATION

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Documentation is defined as written

evidence of:
1.The interactions between and
among health professionals, client,
their families, and health care
organization
2.The administration of tests,
procedures, treatments, and client
education
3.The results or client response to
these diagnostic tests and intervention

BENGKEL NURSING HOSPITAL USM

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The importance of documentation in

nursing practice:
Documentation in the health record
is an integral part of safe and
effective nursing practice.
Clear, comprehensive and accurate
documentation is a record of a
judgement and critical thinking
used in professional practice and
provides an account of nursings
unique contribution to health care
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BENGKEL NURSING HOSPITAL USM

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 Documentation provides written records that

reflect client care provided on the basis of
assessment data and the clients response to
interventions

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BENGKEL NURSING HOSPITAL USM

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 Nurses rely on documentation tools that

support the implementation of nursing process
These tools are: -charting records

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PURPOSES OF
DOCUMENTATION
Communication patient progress
Accountability not charting, not done
Legislative requirements insurance claim ,
Anything written or printed, relied on as
proof for authorized person
Quality improvement - accreditation
Research
Funding and resource management

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Methods of documentation
Narrative charting story format
Source-oriented charting narrative recording
by each member of health care team on
separate records
Problem-oriented charting focus on clients
problem SOAP/SOAPIER
Nursing process

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BENGKEL NURSING HOSPITAL USM

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Forms for recording data

Kardex medication prescription
Flow sheets observational chart, intake &
output chart, medication chart, blood results
chart, etc
Nurses progress notes
Discharge summary
Computerized documentation

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Nursing
documentation
must make
sense, must have
meaning, and
must
communicate.
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Remember!
The basics for good
documentation and verbal
reporting is to protect
yourself legally and to be
able to provide good care to
your patients
Thank You
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ANY QUESTIONS

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