Legal and Ethical Practice

Consent and advance directives

• Valid consent: competent adult, informed, voluntary. Minors need a parent or guardian, except emancipated minors and situations allowed by state law (e.g., STI, contraception, pregnancy care).
• In a true emergency, implied consent applies.
• Advance directives: living will (wishes) and durable power of attorney for health care (decision-maker). Ask about them on admission (Patient Self-Determination Act).
• DNR means no CPR, not "no care". POLST: portable medical orders for seriously ill patients.
• Leaving against medical advice: explain risks, notify the provider, have them sign the AMA form if willing, document.

Privacy (HIPAA)

• Share only the minimum necessary, only with people involved in care or authorized by the patient.
• No details by phone unless the caller is verified (e.g., a code or password).
• Never post anything about patients on social media, even without names.
• Patients can see and request copies of their records.
• Log off; don't look up records you don't need (including your own family's).

Documentation

• Facts, objective, timely; quote the patient where useful.
• Errors: follow the electronic correction process (paper: single line, "error", initials). Never delete, erase or use correction fluid.
• Late entries labeled as late.
• Incident reports are for quality improvement: don't mention them in the chart; document only the event and care given.

Mandatory reporting

• Suspected child abuse or neglect, elder or dependent-adult abuse (proof isn't required).
• Certain communicable diseases (to the health department).
• Some injuries (e.g., gunshot wounds), per state law.
• Impaired or unsafe practice by a colleague: report through the chain of command.

Good Samaritan laws protect emergency care given in good faith, within your training, off duty and without payment.