Mark Advance Directive Made Easy

E signature advance directive

all right in this video we are going to start off by talking about informed consent so if a patient's going to have some kind of surgery or invasive procedure they will need to consent for that surgery or procedure so it's really important for you to know what is the responsibility of provider and what is your responsibility as the nurse when it comes to informed consent so it is the providers responsibility to provide the purpose of the procedure and a complete description of the procedure in the patient's primary language so if needed a medical interpreter may need to be brought in to make sure the patient understands the procedure the provider were should also provide the risks versus benefits of having the procedure and they also need to describe alternatives to having a particular procedure so if they don't have the surgery what else that can they do to address the situation your job as the nurse is to make sure the provider gave the patient all of that information you need to make sure the patient is competent to give informed consent so this means they're an adult or an emancipated minor and they're not impaired by like drugs or alcohol or dementia they're competent and they they can make this decision on their own and then you need to have the patient sign the consent document and if the patient has further questions about the procedure they really don't understand you know the procedure or they have questions about the risks or the benefits etc you need to call the provider and have them come back and explain those things to the patient before they sign that consent document so it is not your job as a nurse to explain those things the procedure and the risks and benefits and alternatives those things need to be explained by the provider you're just making sure the patient is competent they understand the information and that they sign the document okay let's talk about advanced directives now in mandatory reporting so with advanced directives you can have a living will and this is basically a document that communicates the patient's wishes regarding medical treatment if they should become incapacitated one day so it can communicate wishes such as I don't want to be on a ventilator or I don't want to have tube feeding that type of thing you can also the patient can also designate a D POA or durable power of attorney so this person is basically a healthcare proxy that will make decisions for the patient should they become incapacitated and then you can also have providers orders so the provider can write a prescription for a DNR do-not-resuscitate or a nd allow natural death if that is the patient's wish and then in terms of mandatory reporting for RNs as an RN you are obligated and legally required to report suspicions of abuse so this may be of a child it could be of an elderly patient or a victim of domestic violence so when you are caring for the patient of course you're gonna do your full assessment and get a health history but if you suspect abuse you need to go ahead and report that you're not going to wait to gather a lot more data you're not going to like play detective or you know go try to interview different people and and be that detective if you suspect abuse you report it and then the proper authorities will like further that investigation you are also obligated and legally required to report communicable diseases to local and state health departments this is mandated by the state so you just need to know what your state requires in terms of reporting of communicable diseases okay so that's mandatory reporting and then the last thing I want to go over in this video are some key points regarding nursing documentation so when you are doing your documentation you're gonna be documenting objective data so this includes what you see what you hear what you feel what you smell you do not want to include opinions or interpretations of the data so you're not going to say his wound is infected you may say his wound is now odorous there is yellow purlins drainage there's erythema around the wound you're gonna give all of that objective data but not interpret it and then you can include subjective data so this is where you would document like direct quotes or clearly identify information as a statement by the patient so in your documentation you could say patient states that his stomach feels like a chainsaw is going through it and put that in quotes right so you can include like quotes from the patient or subjective information from the patient and then in terms of some legal guidelines regarding documentation you do not want to leave blank spaces in your documentation you would never use correction tape or fluid or scratch out or blackout words so a lot of times we're doing electronic charting now but in some cases there may still be some paper out there and if we are doing paper charting out there you're not blocking anything out or scribbling out stuff or using wite-out or any that and then you always want to include your name and title on your documentation okay incident reports this is a really important one to know about so when an accident or an unusual event occurs such as a medication error or a fall you are going to fill out an incident report for your facility it is used for quality improvement at the facility so they can really evaluate what went wrong why did we have this medication error are there things we can improve or do differently to help prevent this from happening in the future so it's used by the hospital to try to treat like the underlying cause when one of these events occurs however the incident report is not part of the patient record and it should not be referenced in the patient's medical record so you do need to document what occurred like if a medication error happened you have to document what medication was given and what dose was given etc and you have to document the patient's reaction to that medication but the instrument port is separate and it's for the hospital and you don't reference it from the patient medical record so I hope that's clear because that's an important one to know if your test for sure okay so I'm gonna stop here we'll pick it up with more good information in my next video Thanks