48 Questions
What is the purpose of documenting subjective data?
To support objective data with the client's perspective
What should nurses avoid when documenting objective data?
Using derogatory words or judgments
What is the significance of a medical record?
It is a confidential, permanent, and legal document
How should nurses document the client's behavior?
Describing the behavior in detail, without interpretation
What is the responsibility of nurses regarding confidentiality?
Ensuring confidentiality by not sharing client information
What should nurses aim for when documenting facts and information?
To document facts and information precisely
Why is it important to support subjective data with objective data?
To provide a more comprehensive view of the client's condition
How should nurses document a client's statement?
By quoting the statement directly
What should a nurse do when an individual inquires about a client's status?
Ask the individual for the code and disclose information only when the code is correct
What is the primary purpose of a code system in hospitals?
To identify authorized individuals who can receive client information
Where should communication about a client's status take place?
In a private setting where unauthorized individuals cannot overhear
What is a key aspect of HIPAA regulations?
Protecting client confidentiality and privacy
What should a nurse do before using social networking sites for work-related communication?
Become familiar with the facility's policies regarding social networking
What type of data is included in the 'S' section of the SOAP medical record?
Subjective data
What is the purpose of the 'P' section of the PIE medical record?
To document the client's intervention plan
What should a nurse do to maintain confidentiality when using social media for work-related communication?
Avoid using social media for work-related communication
When contacting a provider or other members of the interprofessional team, what is important to do?
Have all the data ready prior to contacting and use a professional demeanor.
What is the primary purpose of the Privacy Rule in HIPAA?
To protect all written and verbal communication about clients.
What should be documented when making a telephone report?
The name of the person who made the call, the time, and the content of the message.
Why is it important for nurses to be aware of clients' rights to privacy and confidentiality?
To protect clients' personal information from unauthorized access.
What is the primary benefit of facilities' policies and procedures regarding HIPAA?
To ensure compliance with HIPAA regulations.
What is the purpose of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)?
To ensure the confidentiality of health information.
What should be included in a telephone or verbal prescription?
The medication, dosage, and instructions for administration.
When should a nurse correct an error in a medical record?
As soon as possible after the error is discovered.
When correcting an error in a medical record, which of the following actions is appropriate?
Drawing a single line through the incorrect entry and initialing the correction.
According to HIPAA, which of the following individuals can request a copy of their medical record?
Client themselves
When documenting client information, which of the following guidelines should nurses follow?
Document both subjective and objective data in a clear and concise manner.
When receiving a verbal prescription, which of the following actions is appropriate?
Repeat the prescription back to the provider and document it in the medical record.
What is the primary purpose of confidentiality in medical records?
To maintain client trust and privacy.
When communicating client information, which of the following actions is a violation of HIPAA?
Discussing client information at the nurses' station.
What is the primary purpose of a medical record?
To document client information and treatment plans.
When documenting a verbal prescription, which of the following is required?
The provider's signature on the prescription.
Who can access a client's medical record?
Only healthcare team members directly responsible for the client's care
What should a nurse do when receiving a telephone prescription?
Repeat the prescription back to the provider, including the medication's name, dosage, time, and route
What should a nurse do if a prescription seems inappropriate for the client?
Question the provider about the prescription
Where should medical records be kept?
In a secure area, accessible only to authorized personnel
What should a nurse do if they need to correct an error in a medical record?
Document the correction in a separate note, with the date and time of the correction
What should a nurse do when sharing medical records with other facilities or providers?
Use a secure, password-protected system to share the records
What should a nurse do when a client requests a copy of their medical record?
Verify the client's identity and provide a copy of their medical record
What should a nurse use to access electronic medical records?
Their own unique password
What is the primary reason for documenting the name of the person who made a telephone report?
To ensure accountability in case of an error
When correcting an error in a medical record, what should a nurse do?
Strike through the error and initial the correction
What is a key principle of documentation guidelines in medical records?
Using exact, relevant, and accurate information
What is a primary responsibility of nurses regarding confidentiality?
Maintaining confidentiality of client information at all times
What is a critical component of a telephone or verbal prescription?
The medication dosage and frequency
What is the primary purpose of the Privacy Rule in HIPAA?
To promote the use of standard methods of maintaining confidentiality
What is a key benefit of facilities' policies and procedures regarding HIPAA?
Ensuring compliance with HIPAA regulations
What is the primary consequence of non-adherence to HIPAA regulations?
Financial penalties and legal liability
Study Notes
Confidentiality in Nursing Practice
- The medical record is a confidential, permanent, and legal document that is admissible in court.
- Nurses are legally and ethically responsible for ensuring confidentiality and accurate documentation of client information.
Documenting Client Information
- Document subjective data as direct quotes or summaries, and identify the information as the client's statement.
- Objective data should be descriptive and include what the nurse sees, hears, feels, and smells.
- Document client behavior accurately, avoiding derogatory words, judgments, or opinions.
Management of Confidentiality
- Nurses must not disclose clients' information to unauthorized individuals or family members without consent.
- Many hospitals use a code system to identify individuals authorized to receive client information.
- Communication about a client should only take place in a private setting where unauthorized individuals cannot overhear.
HIPAA Regulations
- The Health Insurance Portability and Accountability Act of 1996 (HIPAA) aims to ensure the confidentiality of health information.
- Each facility has specific policies and procedures to monitor staff adherence to HIPAA regulations.
- The Privacy Rule requires nurses to protect all written and verbal communication about clients.
Telephone Reports
- Telephone reports should be used to contact the provider or other members of the interprofessional team.
- Nurses should have all necessary data ready, use a professional demeanor, and provide exact, relevant, and accurate information.
- Document the name of the person who made the call, the time, content of the message, and any instructions or information received.
Social Media Precautions
- Nurses should be aware of the implications of HIPAA before using social networking sites for school- or work-related communication.
- Facilities have specific policies regarding the use of social networking, and nurses should become familiar with these policies.
HIPAA Privacy Rule
- The HIPAA Privacy Rule promotes the use of standard methods of maintaining the privacy of protected health information (PHI) among health care agencies.
- Nurses must be aware of clients' rights to privacy and confidentiality.
- Facilities' policies and procedures help ensure adherence with HIPAA regulations.
Telephone Prescriptions
- When receiving a telephone prescription, the nurse should:
- Have all the data ready prior to contacting the provider
- Use a professional demeanor
- Use exact, relevant, and accurate information
- Document the name of the person who made the call and to whom the information was given; the time, content of the message; and the instructions or information received during the report
- Repeat the details of the prescription back to the provider
- Have another nurse listen to the telephone prescription
- Obtain the provider's signature on the prescription within 24 hours
- Question any prescription that seems inappropriate for the client
Omission of Prescription
- Missed specimen collection of a prescribed laboratory test is an example of omission of prescription.
Confidentiality and Access to Client Health Information
- Only health care team members directly responsible for a client's care can access that client's record.
- Nurses cannot share information with other clients or staff not caring for the client.
- Clients have a right to read and obtain a copy of their medical record.
- Nurses cannot photocopy any part of a medical record except for authorized exchange of documents between facilities and providers.
- Staff must keep medical records in a secure area to prevent inappropriate access to the information.
- Electronic records are password-protected, and staff must use only their own passwords to access information.
Test your knowledge on confidentiality and documentation in nursing, including subjective and objective data, and the management of care.
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