Leadership, ethics, legal, documentation
A five-rung escalation ladder with a return arrow labeled care continues, beside a four-box documentation chain of event, assessment, action, response, with an unconnected occurrence report box set apart below it.
The non-clinical rules decide a surprising share of exam items. Learn them as decisions rather than as vocabulary.
Consent The provider performing the procedure explains it and obtains consent. The nurse witnesses the signature and confirms the patient understood. If the patient cannot describe the procedure in their own words, the nurse stops the process and calls the provider back rather than explaining it personally.
Refusal A competent adult may refuse any treatment, including one that is life-sustaining. The nurse documents the refusal, the explanation given, and the notification of the provider. The nurse does not persuade, and does not proceed.
Advance directives A living will states the patient's wishes. A durable power of attorney for health care names the person who speaks when the patient cannot. That named decision maker follows the patient's known wishes, not their own preference.
Privacy Access to the record is limited to those involved in the patient's care. The tested violations are hallway conversations, unsecured screens, and anything posted to social media, not legitimate chart access by the care team.
Mandatory reporting Suspected abuse or neglect of a child or a vulnerable adult is reported by the nurse on suspicion, not on proof, and reporting in good faith is legally protected. The nurse does not need permission from the family, the provider, or the manager.
The error Assess the patient and make them safe first. Notify the provider. Document the facts of what happened and what was done in the medical record. Complete an occurrence report separately. That report is an internal quality document and is never referenced in the chart.
Documentation Objective, timely, specific, attributable. Correct an entry with a single line through it, the facility's convention for marking the correction, and your initials. Label late entries as such with both times. Never chart in advance and never chart for another nurse. No abbreviation from the ISMP Do-Not-Use list appears in any entry.
Chain of command When a patient is unsafe and the provider does not respond, escalate upward through the defined chain rather than stopping at one attempt. Continuing to care for the patient while escalating is part of the correct answer.
Margin notethe chart is the testimony.
Watch outnever chart that an occurrence report was filed. The Nurse Practice Act is state-specific and supersedes any general rule printed here.
TakeawayWhen an item turns legal, protect the patient, document objectively, and escalate through the defined channel.
→ BOOK 03 · P4 for delegation and supervision · → P22 for error barriers · → BOOK 15 · P12 for charting formats and handoff