Archer Review fundamentals.

Fundamentals Archer Review Crash Course Welcome! ● Please stay muted so that there is no background noise. ● If you have a question please enter it in the chat and I will respond as quickly as possible! ● We will be taking two 10 minute breaks throughout the course Introduction ● Morgan Taylor, BSN, RN, CCRN ● Pediatric nurse at heart ● Units I’ve worked on: ○ PICU ○ PCICU ○ NICU ○ Mother-Baby ○ ED ○ Bone Marrow Transplant ● Current position: Children’s Resource Unit… a little bit of everything pediatrics! ● Fun fact: I got married in my backyard this year because….COVID. My niece and nephew totally stole the show! Advanced Directives Advanced Directives & Living Wills ● Advanced Directive: a set of instructions someone prepares in advance of ill health that determines his healthcare wishes. ● Living Will: one type of advance directive that becomes effective when a person is terminally ill. ● Legal documents ● Prepared for when the patient is not able to communicate their own wishes ● Can specify DNR, Full code, or specific interventions Good to know... If summoned, EMTs are legally obligated to provide emergency care to a patient, regardless of advance directive status. If the patient is brought to a hospital, physicians will evaluate the patient and implement the advance directive, if necessary. While some states do honor an advance directive from another state, others do not. For this reason, it is essential for anyone who is moving to a new state (permanently OR temporarily) to update their advance directive to the original state in which they will reside. Advance directives don’t expire. If a new advance directive is created, the most recent one will be honored when presented to medical personnel. If there is no one available to make medical decisions for a patient who appears incapable of doing so, two physicians must evaluate the client and make a recommendation regarding the patient’s decision-making ability. Medical Power of Attorney ● Legal document ● Designates a specific person to make medical decision for the patient should they be unable to make their own decisions ● If the patient doesn’t have a MPOA laws vary state by state on who the decision goes to Legal Concepts Federal Laws to know ● Health Insurance Portability and Accountability Act ○ HIPAA ○ Will discuss further :) ● American Disabilities Act – ADA ○ A civil rights law that prohibits discrimination against individuals with disabilities in all areas of public life, including jobs, schools, transportation, and all public and private places that are open to the general public. ● Emergency Medical Treatment and Active Labor Act – EMTALA ○ Requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay Terminology ● Tort: A wrongful act or an infringement of a right ● Negligence: Failure to take proper care in doing something. ● Malpractice: Improper, illegal, or negligent professional activity or treatment,. ● Assault: An act, criminal or tortious, that threatens physical harm to a person, whether or not actual harm is done. ● Battery: Unconsented physical contact with another person, even where the contact is not violent but merely menacing or offensive. ● False Imprisonment: The state of being imprisoned without legal authority. HIPAA Health Insurance Portability and Accountability Act ● Protecting patient health information ● Specific rules about sharing this information ● If someone doesn’t NEED the information to do their job, DON’T share it with them. ○ Can share with other health care providers that need it to take care of the patient ○ Can share with their family WITH the patient’s permission. How you can protect your patient’s information ● Turn off your computer screen when not using ● Do not speak about patients in a public place ● Shred personal health information ● NEVER post information about patients on social media ● Don’t use computers that are not secure for PHI ● Don’t send PHI to your personal email ● Don’t open the chart of patients you’re not taking care of. Documentation If it wasn’t documented, it wasn’t done! ● Your charting is a part of the patient’s medical record ● Other healthcare providers as well as the patient can see it ● It can be used in a lawsuit ● It’s subject to review by different agencies: ○ The Joint commission ○ Medicare/Medicaid ○ Quality assurance committees DO Chart in real time Chart under your name Chart events accurately, without any subjective opinions:. Ex: Pt stated ‘get out of my room you ugly cow’ DON’T Delay charting Chart early Char under someone else Chart for someone else Allow someone else to chart under your name Chart your opinion of a patient: Ex: Pt was rude to nurse Change another persons documentation SBAR