10. GOVERNING RULES OF PROFESSIONAL NURSING ORGANIZATION

4. LEGAL ISSUES WITHIN PROFESSIONAL NURSING ORGANIZATION

a. Maintenance of Records: All legal documents, such as official time sheets, patient classification documentation, licensure reports, quality assurance, and nursing minutes will be kept for a period of three (3) years.

b. Leaving Against Medical Advice: Refer to Clinical Programs Policy PS 2.05.

c. Witnessing Documents (operative, procedural, wills, & legal documents of patient) : Refer to Clinical Programs Policy ML 1.01.

d.     Consents: Procedural and Operative. See Clinical Programs Policy ML.1.01.

e.     Advance Directives: see Addendum J.6. and Clinical Programs Policy PS.2.07.

f.     Dealing With Suicidal Patients. Patients who are at risk for self-harm will be assessed according to Assessment Standards Addendum I.

g.     Dealing with Unruly Patients/Visitors. Nursing staff should consult the Nursing Administrator on duty regarding the best course of action in handling disturbed or disturbing patients and visitors.

h.     Notation of Physician Orders, Telephone and Verbal.   Telephone/Verbal orders should be employed only when the physician does not have access to electronic order or in an emergent situation.  Medical care may be given in University Hospital only by or on the order of a physician who has been granted medical staff privileges. Orders shall be complete and specific (see Addendum J.8 and Addendum M.1). Hospital nursing staff has the right and obligation to question any order that is illegible, ambiguous, incomplete or seemingly inappropriate. (see Addendum M.1 and Clinical Programs Policy MS.4.01)
The method for transcription of physician orders can be found in Addendum J.8. The procedure for 12 and 24-hour chart check can be found in Addendum J.9

i.     Alcohol (ETOH) Blood Testing.  Blood alcohols may be drawn for the purpose of medical diagnosis and treatment. For police situations where DWI suspects are concerned, please refer to Addendum J.10.

j.     Accessing Medical Ethics Advisory Committee.   The Medical Ethics Committee is a standing multidisciplinary committee of the Medical Board. Meetings of the Medical Ethics Advisory Committee are held quarterly and on-call. If nursing personnel have a concern they may bring that concern to a member of the Medical Ethics Consult Services. (Addendum J.11)

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