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1. 2. Unlicensed assistive personnel (UAP)

1.1. RN shouldn't delegate any task to UAPs.

1.2. Supervision of UAP is a growing responsibility of the licensed practitioner.

2. 1. Nurse practice acts (NPA)=Nursing law

2.1. Determine qualifications for entry into professional nursing (Licensed professional nurses).

2.2. Define educational responsibilities.


2.3.1. 1. Safety.

2.3.2. 2. Quality.

2.3.3. 3. Define & limit the nursing practice.


2.4.1. 1. Nursing process.

2.4.2. 2. Supervision & executing the care plan.

2.4.3. 3. Health maintenance & prevention.

2.4.4. 4. Basic & advanced nursing practicw.

3. 3. Consent

3.1. The PT's acknowledgment & acceptance of treatment.

3.2. TREATMENT without consent ca constitute battery.

3.3. TYPES

3.3.1. Implied Ex: unconsciousness.

3.3.2. Informed Full understanding of risks & benefits of the procedures. Ex: surgery, invasive procedures. ESSENTIAL COMPONENTS Explanation Discuss risks & benefits of the procedures. Alternatives to the procedures.

3.3.3. Involuntary Patient refuses to consent to needed medical treatment. Ex: Psychiatric or Intoxication.

3.3.4. Express Written or oral agreement to treatment. Assessment, medications... Allow any appropriate treatment in an emergency situation.

4. 12. Interfacility transfers

4.1. Hospital must do

4.1.1. Provide appropriate medical screening.

4.1.2. Provide appropriate stabilization treatment.

4.1.3. Obtain written informed consent from the PT.

4.1.4. Verify that the receiving facility has available space & qualified personnel to treat PT.

4.1.5. Ensure that the receiving facility have accepted the PT.

4.1.6. Transfer of the PT with appropriate personnel.

4.1.7. Forward all documents and medical records.

5. 11. Documentation

5.1. Medical record should be

5.1.1. Clear.

5.1.2. Factual.

5.1.3. Composed of one's own observations.

5.1.4. Free of opinions and ambiguities.

5.1.5. Without spelling errors.

5.1.6. Unapproved abbreviations.

5.2. Electronic health record (EHR) is used to

5.2.1. Show continuity of care.

5.2.2. Demonstrate allergy cross checking.

5.2.3. maintain a current medication list.

5.2.4. Provide electronic laboratory recording.

6. 4.Advance directives

6.1. Written statements of treatment choices whenever a PT is no longer able to communicate his wishes.

6.2. TYPES

6.2.1. Living will Wishes regarding life sustaining treatment (withdrawing, forgoing) AS organ transplantation.

6.2.2. Durable power of attorney for health care Make decisions for PT concerning medical treatment. Health care proxy

6.2.3. Don't resuscitate order(DNR) Legal document detailing PT's own preference for future medical care. No CPR

7. 6. Restraints

7.1. Physical Restraints

7.1.1. Any manual method or mechanical devices.

7.1.2. COMPLICATIONS Skin breakdown Delirium, agitation and fear. Deconditioning. Death due to asphyxia.

7.2. Medical Restraints

7.2.1. A drug used to control behavior.

7.2.2. COMPLICATIONS Respiratory depression. Hemodynamic instability. Decrease competency or judgement. Withdrawal symptoms (agitation).

8. 5. Confidentiality

8.1. Relationship between ER nurses and their PTs


8.2.1. Written release is signed by PT.

8.2.2. Ordered into court by a legal authority.

8.2.3. For the purpose of continuity of care.

8.2.4. Filling the insurance billing forms.

9. 10. Unusual events

9.1. Must be documented in incident reports.

9.2. Incident report contain no language admitting liability or blaming others.

9.3. Common reportable events

9.3.1. ERRORS Nursing process Educate PT Medications PT falls

10. 9. Forensics

10.1. Evidence collection

10.1.1. Crucial to understand processes to ensure uncontaminated evidence.

10.2. Evidence preservation

10.2.1. Place all evidence collected in a cardboard evidence box.

10.2.2. Label it with PT name, date, medical record number and signature of the collector.

10.2.3. Secure all evidence retrieved and place in a designated location.

10.3. Chain of custody

10.3.1. Documented record of how the evidence was collected, labeled and transferred to law enforcement representatives.

11. 7. violence & workplace safety

11.1. Violent acts(any act of aggression & can be physical, verbal, emotional assaults).

11.2. Each organization has its own violence prevention program.

12. 8. Reportable conditionss

12.1. Legal responsibility of ER nurse to ensure proper reporting.

12.2. Situations

12.2.1. Any death in ED and deaths within 48 hrs of hospital admission

12.2.2. Abuse Elder Child Disabled adult

12.2.3. Communicated diseases

12.2.4. Extensive burns