Documentation & Legal Standards Flashcards

A nurse discovers she forgot to document a PICC dressing change performed 6 hours earlier. What is the most appropriate action?

Answer: Write a late entry labeled as such with the current date and time, referencing the actual time of care

Late entries must be clearly identified as late, dated and timed when written, and reference when the care actually occurred.

Which element is essential when documenting the removal of a peripherally inserted central catheter?

Answer: Catheter length removed compared with the documented insertion length and tip integrity

Comparing removed length to insertion length and inspecting the tip confirms the entire catheter was removed and no embolized fragment remains.

Under the doctrine of respondeat superior, who may be held liable for a staff nurse's negligent catheter insertion performed within the scope of employment?

Answer: The employing facility, in addition to the nurse

Respondeat superior makes employers vicariously liable for employees' negligent acts within the scope of employment, though the nurse remains individually accountable.

A patient with decision-making capacity refuses a midline catheter after a full explanation of risks. What should the nurse document?

Answer: The information provided, the patient's stated refusal in their own words if possible, and provider notification

Informed refusal documentation should show what education was given, the patient's decision, and that the provider was notified.

Which statement about documenting an infiltration using a standardized scale is most accurate per INS guidance?

Answer: A validated, standardized scale should be used and the assessment findings, interventions, and outcome recorded

INS recommends standardized assessment tools and documentation of findings, actions taken, and patient response for infiltration and extravasation.

Which is the BEST example of objective documentation of a peripheral IV site?

Answer: Erythema 3 cm proximal to insertion site, palpable cord 2 cm, patient rates pain 5/10

Objective documentation uses measurable, observable findings rather than opinions or vague terms.

An unusual occurrence (incident) report about a catheter-related injury should generally be:

Answer: Completed per facility policy and kept separate from the medical record, while the clinical facts are charted

Incident reports are quality/risk-management tools kept out of the medical record; the chart contains only the objective clinical event and response.