Chapter 5: Confidentiality and Documentation

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.