Documentation & Legal Standards Flashcards

For a nurse to be found liable for negligence, which four elements must be proven?

Answer: Duty, breach of duty, causation, and damages

Negligence requires a duty owed, a breach of the standard of care, causation linking breach to injury, and actual damages.

In a vascular access malpractice case, the standard of care is most commonly established by:

Answer: Expert testimony, professional standards such as the INS Standards of Practice, and facility policies

Courts rely on expert witnesses, published professional standards, and institutional policies to define what a reasonably prudent nurse would do.

Which documentation is required to verify central venous access device tip placement before initial use?

Answer: Confirmation of tip location by an approved method (e.g., chest radiograph or ECG-guided technology) documented in the record

INS recommends tip location be confirmed and documented before CVAD use; blood return alone does not verify position.

A nurse charts a peripheral IV insertion she did not perform because the inserting colleague was busy. This action is best described as:

Answer: Falsification of the medical record

Documenting care you did not personally perform or witness as your own is falsification and exposes the nurse to legal and licensure action.

Which situation represents an implied rather than expressed consent for peripheral IV placement?

Answer: A patient extends their arm after the nurse explains she will start an IV

Implied consent is inferred from conduct, such as offering an arm after explanation, rather than spoken or written agreement.

When documenting an extravasation of a vesicant, which entry is MOST important to include besides site assessment?

Answer: The estimated volume infiltrated, actions taken (including antidote if given), provider notification, and patient education

Thorough extravasation documentation includes estimated volume, interventions, notifications, and follow-up/education to support continuity and defensibility.

Which is an example of an acceptable correction in a paper medical record?

Answer: Drawing a single line through the error, writing 'error' or per policy, and initialing and dating it

Corrections should leave the original entry legible, with a single line, notation, initials, and date per facility policy.