Legislation that guides nursing practice

1. Legislation that guides nursing practice

2. Health Professionals Registration Act

3. Will it replace the NBV as we know it? • NO

4. Nurses Act 1993(Vic) • Purpose - to regulate the profession of nursing in Victoria, register nurses, and annually renew their status. • Includes accreditation of courses in universities and TAFE sector which lead to the use of the title nurse • Setting practice standards and guidelines, • Provision for complaints process, examining the professional conduct or health of a registered nurse

5. Implications on practice • Nurses have a responsibility to know what the Act encompasses in regard to professional conduct. • Two sections of particular importance are the: Professional conduct information section of the Act and The Professional; Boundaries guidelines for registered Nurses in Victoria. Breaches of either of these sections have a dramatic impact on nurses ability to practice in Victoria.

6. Unprofessional Conduct • Lesser standard • Professional misconduct • Finding of guilt • Failure to act when required • Contravention of the Act

7. How are Complaints Investigated? • Must be in writing • See regulations • Legal support

8. Investigations/Hearings • Professional conduct • Informal hearing • Formal hearing • Process for investigations into professional conducts • “Health matters”-published by the NBV

9. Health Records ActPrivacy and Confidentiality

10. Session summary • Health Records Act / Health Privacy Principles • Freedom of Information Act • Patient brochure, policy • Privacy complaints • SVH Confidentiality Agreement • Assessing work area, environment, processes • Scenarios • Outcomes • Queries/feedback to Team Manager/HIM/Clinical Nurse Educator

11. Privacy Legislation • Health Records Act 2001 • Applies to health information • July 1, 2002 • Sets out Health Privacy Principles to ensure that use information for the purpose it was collected and pts right to privacy is respected

12. Health Privacy Principles 1.Collection 2. Use and Disclosure 3. Data quality 4. Security and retention 5. Openness 6. Access and correction continued

13. Health Privacy Principles 7. Identifiers 8. Anonymity 9. Transborder data flows 10. Transfer on sale, closure 11. Other Health Service Providers Information Privacy Act has similar points 1 - 10

14. Points to Note • Ownership: property and responsibility of the area health service. • Other legislation takes precedence such as the Mental Health Act (s 120A), Children and Young Persons Act. • Follow hospital policy in handling of confidential (ie patient’s) information

15. Features of HRA Patient knowledge • Onus on Health Services to inform patient what information we hold and how we use it • Patient choice about release of their information • Most of these issues are not new but a new law has served as a reminder of professional responsibilities • Patients are already more aware of their rights and have higher expectations

16. What We Need to Do:- Patient Brochure • Aim to provide patients with reasonable expectation as to what happens to their information. • We give patients an opportunity to read/receive “Privacy and your Health Information”. • Brochure must be given before or at the time of information collection, on contact with our service (all sites: inpatients, community). • Ask “Have you received this brochure before?” – “Please take some time and read the brochure as it relates to what happens to your information.”

17. Access and Correction • Public Hospitals still governed under Freedom of Information Act (FOI) • FOI process at individual health services: policy & application form • “FOI Exempt” entry in the medical record • Level of access has not changed • FOI has been amended to enable another way of accessing information • - After FOI process completed, patient can view the record and have it explained. (May still request that any information they feel is incorrect be amended - refer this to Director of Clinical Services)

18. Disclosure Legal provisions permit disclosure, they do not require it. In deciding to disclose, you need to consider: • Purpose: what level of information would meet the purpose • Amount: how much information would meet the purpose • Consumer’s best interest; what will disclosure achieve in the consumer’s interest • Other relevant legislation: guidelines and other ethical requirements Where possible, always try to obtain client’s consent.

19. Confidentiality Agreement • All new and current staff are required to sign a health service wide confidentiality agreement • As part of the agreement, must have read the Privacy and Confidentiality policy • A breech of the agreement may result in disciplinary action, including written warnings and termination of employment

20. Risk Assessment Need to assess your work area for privacy breaches • Assess your physical environment • Assess your work processes Privacy issues that can be fixed through reasonable steps should be rectified ASAP • Departments will be audited for compliance

21. Physical Environment • Computer screens angled away from public view. • Fax machines in an area where staff are in attendance. • Confidentiality clause on all fax lead sheets • Use of confidential shredding bins to dispose of identifying information that is not to be stored in the record (eg:handover sheets) • Appropriate storage and handling of confidential information – medical record, handover sheet, pt labels • Diaries, Palm Pilots, Whiteboards: confidential information – as above

22. Work Processes Medical Records • Storage: approved standard locations: Medical Records room. Must be secure and accessible by authorised users. • Patient access to medical record for MHRB differs from FOI. Transporting information – x-rays, records. Have information facing down, use grey plastic bags. • On community visits: medical record and confidential information must be secure in accordance with the act.

23. Work Processes • Log off the computer when finishing a session • If leaving the computer for a brief period, change to a generic screen with no identifying information on it. • Access to RAPID: only authorised/warranted/justified use • Do not discuss information in public areas e.g.Lifts/corridors/reception • Confidential subjects discussed in private settings where possible. • Cautious use of portable/mobile phones for confidential discussions

24. Work Processes • Fax with caution – double check number dialed correctly • Have a set place to store information and make sure it is stored securely Any person who accesses information (or when information is communicated) must be authorised,warranted and justified to receive the information. Does this include Family? Friend? Police? Landlord? Other patients? Visitors to other patients? Courier?

25. Outcomes • Patient and staff are aware that privacy and confidentiality is maintained • Where possible, patients have more knowledge and choice • Whenever staff deal with information they consider confidentiality issues • Staff information handled under similar principles to patient information

26. Documentation and the Health Records Act

27. What is a Medical Record

28. Why Document? • The making of notes is a fundamental communication exercise in health care. • Notes often form the basis for further communication between team members, and across time in dealing patients. • Written reports constitute an ongoing account of the patient’s stay in hospital. • And, from time to time, a patient’s medical records will be required as evidence in court.

29. Reports as Evidence

30. Considerations The ABC of report writing • Accuracy • Brevity • Completeness

31. Accuracy • It is important to distinguish between what is personally observed and what is related as part of a patient’s complaint of illness or injury. • Unless the assault was actually witnessed, the patient’s complaint of injury is clearly hearsay and must be reported as such.

32. Avoid unnecessary verbosity “If the style of your report writing utilises overly long sentences, or, as is sometimes the case, complex sentence structure with multiple items of information, the salient message intending to be conveyed can ultimately be dissipated and obfuscated causing, not only confusion for the reader, but on those occasions where the author loses grammatical and syntactical control.” Brevity

33. As part of ensuring the reports are complete, reference should always be made where a patient refuses any treatment or medication or acts in a manner contrary to advice. If a patient had been advised to remain on complete bed rest, the fact that the patient insisted on getting out of bed to go to the toilet should be recorded. Completeness

34. Completeness To identify how often and how detailed documentation should be consider: • The complexity of the client’s needs • The degree that the client’s condition, care or treatment puts them at risk • Policies and legal requirements in your clinical setting • Any unusual events: such as transfer, refusal of treatment, accidents, non attendance for appointments etc.

35. Standards for Writing in the Medical Record ·As per the SVH Medical Record Documentation Policy, entries must be: wlegible. wsigned, with the name and designation of the author printed. wdated fully with the time of entry printed win either black or blue pen. All entries in the medical record, including alterations to the record must be legible.

36. Standards for Writing in the Medical Record • Write the DATE and TIME of entry • Your profession (Nursing, Allied Health, HMO) • Reason for entry(i.e. Nursing Entry, Case manger Entry, Statutory Review, Clinical review) at the start of your entry.

37. Standards for Writing in the Medical Record • If documenting a serious event for example absconded client, severe self-harm, serious attempt or actual suicide include the actual time of the incident (i.e. 7.35pm) and a chronological account of incident and subsequent management including outcome.

38. Standards for Writing in the Medical Record • At the end of your entry SIGN, PRINT YOUR INITIAL&SURNAME and DESIGNATION (i.e. RPN, Psychologist). • This is very important because each entry is an account of your actions and will be read by others to ensure that care provided at that time was appropriate etc i.e. Treating team, Case Managers, Coroner.

39. Standards for Writing in the Medical Record • Use a label on EVERY progress note. Each sheet within the medical record should be identified with the client label. • When using a label, ensure the label is for the correct patient, and that the label has the current details on it.

40. Standards for Writing in the Medical Record When you provide a client or family with RIGHTS brochure or other pamphlets i.e. psycho educational material, RECORD it in the progress notes or management plan. (If this is not documented it did not happen)

41. Standards for Writing in the Medical Record Highlighters/ fluorescent markers should not be used at all in the medical record because of reduced reproducibility. they don’t transfer into other mediums e.g.: fax, photocopy or microfilm)

42. Standards for Writing in the Medical Record ·Entries should be made in black or blue pen. Pencil and fountain pens should not be used. • PRN medication to be underlined, with reason required and effects. Not written in red or highlighted. As these mediums do not reproduce well in faxes, photocopies or microfilm. ·No correction fluid is to be used.

43. Standards for Writing in the Medical Record ·A single horizontal line must rule out errors. This must be signed and dated with an explanatory statement i.e. wrong client, wrong medical record. • The same process is used for an unused space on the progress notes. It is not necessary to sign for unused space.

44. Standards for Writing in the Medical Record • Personal, offensive or humorous comments about clients should not be written in the medical record. The medical record is a legal document developed for patient care. It communicates between health professionals.The FOI Act governs us, and inappropriate comments may be released at a later stage to the client or another party.

45. Standards for Writing in the Medical Record • Progress notes, medical, nursing and allied health staff to record all significant events must document observations and consultation reports. • Only abbreviations and symbols acceptable to the facility are used.

46. Standards for Writing in the Medical Record • Entries into the medical record must be made as close as possible to the time of occurrence of the event(s) being documented. • All student entries must be countersigned by their supervisor.

47. FOI Exempt • Freedom of Information (FOI) exempt entries must be indicated with a vertical line drawn along the outside margin. At the top of the entry write “FOI Exempt” inside a box. FOI Exempt

49. The Progress Notes • Documentation is to provide a mental status examination, response to treatment and the rationale for treatment within each entry. • All nursing interventions are to be documented • Care provided over the shift and review of management plan as appropriate to be included • On the Inpatient unit this is done for each shift. The night shift is not expected to follow the same format, as they are limited in their engagement with the client. • In the community it is done for each contact with or with any information obtained regarding that client

50. The Progress Notes • In all entries, issues relating to Nursing Management /Care Plan / ISP are to be addressed. wMental status assessment should include: • Presentation/ Appearance, • Behavior and psychomotor activity, • Affect/Mood, • Thought disturbance, • Thought content, • Perceptual disorders (including whether they are hallucinations, delusions, whether they are self reported/observed, third party report, congruent with affect), • Insight/Judgment, • Cognition/Concentration/Consciousness/Memory, • Risks including category observations. • Include Sleep, Diet/Appetite.