PAMANTASAN NG LUNGSOD NG

MAYNILA

Documentation for
Possible Legal
Problems
BACHELOR OF SCIENCE IN NURSING

GROUP 3: BSN 1-6

 01 CONSENT FORM
Content
Outline 02 INCIDENT REPORT
Topics for discussion

03 HAMA
 What is informed consent?
Informed consent is a client's
agreement to accept a course of
treatment or a procedure after
receiving comprehensive
information about the
advantages and dangers of the
therapy, alternatives to the
treatment, and prognosis if not
treated by a health care
professional.
What is informed consent?

Informed consent is when a

healthcare provider — like a doctor,
nurse, or other healthcare
professionals — explains a medical
treatment to a patient before the
patient agrees to it. This type of
communication lets the patient ask
questions and accept or deny
treatment.
 In a healthcare setting, the process
of informed consent includes:

1. your ability to make a decision

2. explanation of information
needed to make the decision
3. your understanding of the
medical information
PROCESS OF
INFORMED
4. your voluntary decision to get
CONSENT treatment
 CONSENT FORM

What types of procedures need

informed consent?

The following scenarios

require informed consent:

most surgeries
blood transfusions
anesthesia
radiation
chemotherapy
some advanced medical
tests, like a biopsy
most vaccinations
some blood tests, like HIV
testing

ARAICO PHARMACEUTICAL | VACCINES

 Diagnosis of
What should your condition
it include?
An informed Name and
consent purpose of
agreement treatment
should include Benefits, risks,
the following and alternative
information: procedures
Why do you When your healthcare provider
recommends specific medical care,
need to sign you can agree to all of it, or only
a consent some of it.

form? Before the procedure, you’ll have to

complete and sign a consent form.
This form is a legal document that
shows your participation in the
decision and your agreement to have
the procedure done.
When you sign the form, it
means:

You used this You agree, or

information
You received
all the relevant
You to consent, to
information understand determine get some or
about your thisA favorable landscape
whether or not all of
the
procedure from

your healthcare information. you want the treatment

provider.
procedure. options.

Can others sign a consent form

on your behalf?

In some cases, another person can sign a consent
form for you. This is appropriate in the following
scenarios:
You aren’t of legal
age
In most states, if you’re
younger than 18, a parent
or guardian will need to
give consent on your
behalf. But some states
allow teens who are
emancipated, married,
parents, or in the military to
provide their own consent.
You want
someone else
to make the
decisions
If you’d like to let another
person make your future
medical decisions, you can
fill out a form called an
advance directive. This
allows someone else to give
consent on your behalf if
you’re unable to
You can’t give
consent
Another person can
make your medical
decisions if you can’t
provide consent. This
may happen if you’re in
a coma, or have a
condition like advanced
Alzheimer’s disease.
When is Informed consent isn’t always
required in emergencies.
informed In an emergency, your provider may
consent not look for your closest blood relatives
for consent.
required? But if your relatives aren’t available,
or if you’re in a life-threatening
situation, a healthcare provider can
perform the necessary life-saving
procedures without consent.
INCIDENT
REPORT

GROUP 3: BSN 1-6

Incident Report

Pamantasan ng Lungsod ng Maynila | March 2022

An incident is a sudden occurrence that endangers the safety of
patients or staff. Physical injuries, medical errors, equipment failure,
administration, patient care, and other concerns are common in
healthcare events. "Incident.

Reporting in Healthcare" refers to the process of gathering

incident data and appropriately presenting it for action. An
evolving problem is highlighted in a non-blaming manner
through incident reporting to uncover the root cause of the error
or the contributing causes. Nurses or other hospital personnel
often file the report within 24 to 48 hours of the incident. It is
preferable to report instances when memories of the events are
still fresh.
When To Write Incident
Reports in Hospitals?

Pamantasan ng Lungsod ng Maynila | March 2022

WHEN AN EVENT CAUSES HARM TO AN INDIVIDUAL OR
PROPERTY DAMAGE INCIDENT REPORTING BECOMES
MANDATORY.

For example in this

situation:

A nurse is assisting a patient in walking from his bed to

the bathroom. However, he stubs the big toe on his left
foot on the IV pole that he is pulling.

While injecting pain medication into the accident

patient's IV, the nurse misinterpreted the label and
provided a larger quantity than prescribed, raising the
patient's blood pressure.

Pamantasan ng Lungsod ng Maynila| March 2022

Purpose of Incident Reports

Manila Medical School | January 2022

Hospital administrative facilities benefit
greatly from incident reports. They
collect data that will be used to highlight
the essential efforts to improve the
hospital's overall safety and quality. A
thorough incident report serves several
functions.
Purpose of
Incident Reports
1. Root Cause
Identification
Mishaps are not uncommon in hospital settings,
and most incidents can be root-causes for a
potential reason.

Manila Medical School | January 2022

2. Policy and Process
Improvements
Some incidents are part of a larger pattern that
can only be identified by looking at them
together.

3. Clinical Risk
Management
Clinical risk management is a subset of
healthcare risk management. Having the ability
to assess clinical risks ensures the hospitals can
stay ahead in their business and provide high-
quality care.
Purpose of
Incident Reports 4. Continuous Quality
Improvement (CQI)
Having incident reports duly filled and followed
up to closure helps the CQI process to identify
potential areas of improvement.

Manila Medical School | January 2022

5. Better Training and
Continuous Learning

Having a robust incident management system

helps implement a good continuous learning
program for staff. Incident data are essential
sources of knowledge and on-the-job training
material.
Different Types
of Incident
Reporting in
Healthcare
1. Clinical
Incidents
An unpleasant and unplanned event
that causes or can cause physical harm
to a patient. These incidents are harmful
in nature; they can severely harm a
person or damage the property.
For example:
● Nurse administered the wrong
medication to the patient.
● Unintended retention of a foreign object
in a patient after a surgery.
● Blood transfusion reaction.
2. Near Miss
Incidents
Sometimes an error/unsafe condition
might have diffused before it reaches the
patient. Such incidents are called "near-
miss" incidents.
For example:
● A nurse notices the bedrail is not up
when the patient is asleep and fixes it.
● A checklist call caught an incorrect
medicine dispensation before
administration.
● A patient attempts to leave the facility
before discharge, but the security guard
stopped him and brought him back to
the ward.
3. Non Clinical 4. Workplace
Incidents
Incidents
A work accident, occupational incident,
or accident at work is a discrete
occurrence that can lead to physical or
Non-clinical incidents include events,
mental occupational injury. The
incidents, and near-misses related to a
workplace incidents are related to
failure or breach of EH&S, regardless of
mental as well as physical hurts.
who is injured or involved.

For example:
● Patient or next-of-kin abuses a care
provider – verbally or physically –
For example:
● Misplaced documentation or documents
leading to unsafe work conditions.
● A healthcare provider suffered a
were interchanged between patient files.
● A security mishap at a facility.
needle prick while disposing of a used
needle.
 Who Prepares Incident Reports in
Healthcare Facilities?

Some hospitals have designated persons who are authorized to file the reports. In
some other hospitals, the staff usually updates their supervisor about an
incident. Allowing all staff to report requires a training effort from the quality and
safety teams. QUASR clients have been configured to give access to all their staff
so that they can initiate an incident report.
Critical 1. General Information

Components of The well-informed incident report needs basic

information such as the date and time of the

Incident Report
incident. Additionally, for future analysis, your
report must include general information.

2. Location of the
Incident
Specifically, mention the location of the incident
and the particular area within the property. With
the location specifications, administration staff
can better investigate the reason behind the
incident and fix it.

3. Concise yet Detailed

Incident Description
The incident description needs to be clear and
meaningful, don't use vague language, never
add baseless information, and keep personal
biases out.
Critical
Components of 4. Type of the Incident

Incident Report
You should define the nature of the incident while
reporting to get a clear view

5. Information of all
Parties Involved in the
Incidet
The administration needs the name and contact
details of all the parties involved in the incident.
The report should capture all the relevant
information required to follow up with the
involved parties.

6. Witness Testimonies
If there are witnesses available to the incident, it
will be helpful to add their statements in your
report.
Critical 7. Level of Injury

Components of In case of injury, the reporting staff must record

the injury level and cause in the report. If the

Incident Report
incident involves an in-patient at the hospital,
their medical records will reflect the treatment
and diagnosis of the injury.

8. Follow Up
The incident report is incomplete without the
follow-up action details. Each report should
include remarks stating what preventive
measurements and tactics you have opted to
avoid such incidents in the future.

9. Reviews
The goal of the review is to prevent the
recurrence of the incident and create immediate
action plans. A supervisor or manager must
ensure the implementation of corrective actions
against the report.
Critical
Components of
10. SBAR
SBAR abbreviates Situation, Background,

Incident Report
Assessment, and Recommendations. The
reporting person’s supervisor at the time of the
incident typically performs SBAR.

11. Risk Scoring

A risk score is a calculated number that reflects
the severity of risk due to some factors. We
compute risk scores as a factor of probability and
impact. It is common in the industry to use a 5×5
risk scoring matrix

12. Investigation
Information
An information investigation is a thorough
review of all the supporting evidence, which
includes photos, CCTV footage and witness
statements.
Critical 13. Root Cause Analysis

Components of
Root cause analysis is a problem-solving method
used to identify the root cause of

Incident Report
problems.Typical output of the RCA step is a set of
contributing factors that then indicate systemic
issues that may be addressed together by policy
or process changes

14. Contributing Factors

Contributing factors are those factors that
influenced a single event or multiple events to
cause an incident. If contributing factors are
accelerated, it will affect the severity of the
consequences.

15. Executive Summary

The compelling executive summary is the final
step in reporting incidents. It is a short document
produced for management purposes. It
summarizes a more extended report so that
readers can quickly become acquainted with
the material.
Benefits of Hospital Incident Reporting

1. Preventive Measures

One of the most powerful

3. Cost Reduction

elements of an incident By gathering and

report is streamlining analyzing incident data
historical and current daily, hospitals’ can keep
data to spot potential themselves out of legal
incidents in advance. troubles.

2. Disease Monitoring 4. Enhanced Patient

Safetyn
With the incident reports,
healthcare organizations From enhancing safety
can monitor potential standards to reducing
disease outbreaks by medical errors, incident
using past and present reporting helps create a
metrics. sustainable environment
for your patients.
 Healthcare Incident Reporting
Challenges
To create a result-driven incident report, you have to cross the
next hurdles also:

1. Paper-based Reporting
3. Busy Schedule
Paper-based reporting has numerous
The busiest hospital personnel, nurses, and doctors
disadvantages, including low-quality data
are mainly responsible for filing incident reports. Due
and limited flexibility, costly process, error-
to their busy and often overworked schedule, they
prone, time-consuming, and more.
sometimes fail to report incidents.

2. Underreporting
Common causes of underreporting include:

Lack of awareness about when and what to

report.
Fear of repercussions from colleagues or seniors.

 CONCLUSION
After learning about the goal,
benefits, and obstacles of incident
reporting in healthcare, it is
evident that reporting is necessary
for medical facilities. Whether you
want to improve patient safety or
prevent workplace accidents,
incident reporting can help.

 HAMA
Presented by: GROUP 3 (1-6)
LEAVING AGAINST MEDICAL ADVICE

Patients who leave against medical advice are a risk to

themselves and represent a potential medical-legal risk.

In these situations, physicians should try to educate

patients on what symptoms and signs should prompt them
to seek further medical attention.
 DOCUMENTATION OF LEAVING AGAINST
MEDICAL ADVICE

In the medical record document, the discharge instructions are provided.

A signed AMA form is acknowledgment that a discussion with the

patient of the risks of discharge has occurred.

The recommendations for care, the mental capacity assessment, the patient's reasons for refusing
investigation or treatment, and the follow-up and discharge instructions should be documented in the medical
record.

A signed AMA form is potentially useful if issues about the assessment and informed discharge arise later. In
these circumstances some physicians ask nursing staff to witness that an assessment and discussion have
occurred.
 IENT LEAVES AGAINST MEDICAL
R PAT
YOU ADV
EN ICE…
WH

A MENTALLY COMPETENT patient

has the right to leave a facility at any
time, even if his health care providers
judge that he needs to stay for
further treatment
 TAKING AIM AT THE AMA FORM

To protect you and other health care providers caring for the patient
and your facility if problems were to arise from an unapproved
discharge, you should have the patient sign an AMA form. This form
should clearly document that the patient knows he's leaving AMA, that
he's been advised of and understands the risks of leaving, and that he
knows he can come back. Use his own words to describe his refusal to
stay for further treatment.
 HERE'S WHAT TO INCLUDE ON
THE AMA FORM:
explanation of the risks and consequences of the AMA discharge, as
told to the patient, and the name of the person who provided the
explanation
other places the patient can go for follow-up care
names of people accompanying the patient at discharge and the
instructions were given to them
patient's destination after discharge.

If the patient leaves without anyone's knowledge or if he refuses to sign the AMA form,
check your facility's policy; you'll most likely have to fill out an incident report.
 RELATE THE PATIENT’S STATE

In the progress notes, document statements and actions that reflect

the patient's mental state at the time he left your facility. This helps
protect you and other health care providers caring for the patient
and the facility against a charge of negligence if the patient later
claims that he was mentally incompetent at the time of discharge and
was improperly supervised while in that state.
EIGHT PARTS OF THE
AMA PROCESS
1. CAPACITY

This term refers to the patient’s medical ability to make a decision. Documenting that
the patient “understood” offers little protection, while documenting a patient’s ability
to carry on a conversation and demonstrate reason provides a much more compelling
example of their capacity to make decisions. Additionally patients should be noted to
be clinically sober as a way to support their capacity.

2. SIGNS AND SYMPTOMS

The patient and provider need to agree on both the

patient’s symptoms and also the provider's concerns

3. EXTENT AND LIMITATION OF

THE EXAM
Document what has been done as well as the limitations that still exist
4. CURRENT TREATMENT PLAN
Example:
“I have discussed the need for a CT scan to get more information about potential causes
of the patient’s pain.

5. Risks of Foregoing Treatment

Simply documenting “you could die if you leave” is inadequate. The patient should be
informed of reasonably foreseeable complications including disability and death. Specific
threats such as loss of fertility for testicular/ovarian pathology or loss of vision for
ocular complaints should be included when appropriate.

6. Alternatives to Suggested Treatment

Providers should clearly document the efforts they have made to prevent the patient
from leaving AMA.
7. EXPLICIT STATEMENT OF AMA AND ABOUT WHAT THE
PATIENT REFUSED

Example:
“The patient is not willing to undergo a CT scan. He is unwilling to stay overnight for
monitoring. He is refusing any further care and is leaving against medical advice.”

8. QUESTIONS, FOLLOW-UP, MEDICINES, INSTRUCTIONS

When patients leave AMA, providers should do whatever is possible to limit bad
medical outcomes. A commonly held misconception is that providing a patient with
prescriptions or paperwork somehow negates their AMA status and places the
provider at risk
 REFERENCES:
Berman, A., Snyder, S., & Frandsen, G. (2015). Kozier and Erb's fundamentals of nursing: Concepts,
practice, and process. Prentice Hall.
Informed discharge. CMPA Good Practices Guide - Leaving against medical advice (AMA). (n.d.).
Retrieved March 29, 2022, from https://bit.ly/36QuosO
Nunez, K. (2019, October 11). Informed consent in healthcare: What it is and why it's needed.
Healthline. Retrieved March 28, 2022, from https://www.healthline.com/health/informed-
consent#why-its-needed
Prof Liam Donaldson (WHO Envoy for Patient Safety). (2022, March 22). Incident reporting in
healthcare: A complete guide (2020): Quasr Blog. QUASR. Retrieved March 29, 2022, from
https://www.quasrapp.com/blog/incident-reporting-in-healthcare/
The proper way to go against medical advice (AMA): 8 elements to address. ALiEM. (2016, November
12). Retrieved March 29, 2022, from https://www.aliem.com/proper-way-to-go-against-medical-
advice/?fbclid=IwAR0emxX5C_kHN9IyANVJzIp7jubHdKzw23DR3jd24MZcioCLVtSz3TWiBz0
When your patient leaves against medical advice : Nursing made incredibly easy. LWW. (n.d.).
Retrieved March 29, 2022, from
https://journals.lww.com/nursingmadeincrediblyeasy/fulltext/2003/11000/when_your_patient_leave
s_against_medical_advice.2.aspx