The legal side of nursing

The legal side of nursing

Dottie Roberts

As nurses, we flirt with legal disaster every time we walk into a patient care area. Most of us have minimal training in the legal aspects of health care. However, we must be knowledgeable about issues such as patient confidentiality and informed consent, and be able to document patient assessments and responses in a comprehensive, defensible manner. Already stressed by the need to care for more and sicker patients, we work in the shadow of a legal specter. Each of us no doubt wonders at times, “Did I inadvertently share inappropriate patient information with the wrong person?” “Does my patient have enough information to make a truly informed decision about health care options?” “Will my charting reflect my reasonable and responsible actions if I face deposition because of a patient’s lawsuit?”

Knowledge Is Key

Current knowledge is the only way we can be sure we are practicing within the law. First, we should be familiar with the Nurse Practice Act in our states of employment. Each act provides the legal parameters for the practice of professional nursing in that jurisdiction, and was developed primarily to safeguard the public from care by unqualified practitioners (National Council of State Boards of Nursing, 1996). Familiarity with the Nurse Practice Act will also protect each of us by helping us to avoid inappropriate or unsafe actions. The act defines our practice and, when followed in conjunction with our employers’ policies and procedures, guides our responsible decision making.

In addition, federal legislation such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) affects our practice as nurses. As the first-ever federal privacy standards, HIPAA was fully implemented in April 2003. It offered consumers more control over how their personal health information is used and disclosed (U.S. Department of Health and Human Services, 2003). Nurses definitely needed another lesson in legal awareness to help them comply with these standards. Readers of MEDSURG Nursing received an excellent review of HIPAA’s practice applications in a recent article by Frank-Stromborg (2003).

Another frequently misunderstood legal issue is that of informed consent. According to the American Medical Association (2003), the process is more than just gaining a signature on a written consent form; it involves communication between the patient and physician that results in the patient’s agreement to undergo a specific intervention. What is our responsibility as nurses in obtaining informed consent? With varying practices among health care institutions, it’s perhaps no surprise that we may be unsure of our role. In this issue (p. 227), Goodwin provides a thoughtful overview of our legal responsibility in witnessing a patient’s signature on a consent document.

Documentation of patient care is one of the most critical legal tasks we perform as nurses. We must be sure that our documentation is a complete and accurate reflection of our reasonable and responsible actions. Defensive documentation is never more critical than in the situation of a “patient gone bad.” Frankly, I have some concerns about the use of computerized documentation with boxes to check off patient symptoms. This model gives us many shortcuts that can lead to an incomplete medical record. My personal litmus test for adequate documentation is to ask myself if my review of this chart in several years will give me enough information about my patient assessment and subsequent actions to satisfy a lawyer’s questions. If that’s not the case as you review your own notes from your next patient care assignment, I encourage you to add the important details that will fill in the gaps and create a comprehensive medical record.

Also in this issue, Michele Mathes, JD, shares her insights on legal/ethical issues in nursing (Ethics, Law, & Policy, p. 261). I am very excited about this addition to MEDSURG Nursing and encourage you to contact me through the journal office if you have questions for Ms. Mathes to address in future columns. Her regular features will help us all remain aware of the legal side of nursing.


American Medical Association. (2003). Informed consent. Retrieved June 4, 2004, from ama/pub/category/4608.html

Frank-Stromborg, M. (2003). They’re real and they’re here: The new federally regulated privacy rules under HIPPA. MEDSURG Nursing, 12(6), 380-385, 414.

National Council of State Boards of Nursing. (1996). Protection or professional self-preservation? The purpose of regulation. Retrieved June 6, 2004, from

U.S. Department of Health and Human Services. (2003). Protecting the privacy of patients’ health information. Retrieved June 6, 2004, from

COPYRIGHT 2004 Jannetti Publications, Inc.

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