Nursing Ethics and Health Records

<p>Protecting patient records and information management (D)</p> Signup and view all the answers

<p>Supports clinical decision-making processes (C)</p> Signup and view all the answers

<p>Privacy is a broader concept than confidentiality and deals with an individuals desire to keep their own affairs out of the public domain, while confidentiality is a professional legal requirement that requires only healthcare professionals to avoid sharing private patient details (B)</p> Signup and view all the answers

<p>Improves staff communication, and provides immediate access to patient data. (A)</p> Signup and view all the answers

<p>The nurse advocates for and strives to protect the health, safety, and rights of the patient. (A)</p> Signup and view all the answers

<p>A client suffering a severe injury due to an unexpected adverse event (D)</p> Signup and view all the answers

<p>Activate the fire alarm and follow facility protocols (D)</p> Signup and view all the answers

<p>Aim the nozzle at the base of the fire (C)</p> Signup and view all the answers

<p>Moving the client to a side-lying position (A)</p> Signup and view all the answers

<p>4 hours (C)</p> Signup and view all the answers

<p>Tying a wrist restraint to a side rail of the bed (B)</p> Signup and view all the answers

<p>Requesting a sitter (B)</p> Signup and view all the answers

<p>Class C (A)</p> Signup and view all the answers

<p>A suction machine and oxygen (C)</p> Signup and view all the answers

<p>Placing all the client's needed items out of reach (D)</p> Signup and view all the answers

<p>A patient's social security number (A)</p> Signup and view all the answers

<p>Downloading a patient’s full medical chart onto your personal laptop (A)</p> Signup and view all the answers

<p>Subjective data as direct quotes or summarized statements along with objective data (C)</p> Signup and view all the answers

<p>Draw a single line through the error, initialing, and indicating 'mistaken entry' (B)</p> Signup and view all the answers

<p>Make a late entry, indicating the time of the event and the actual documentation (D)</p> Signup and view all the answers

<p>Patient states, 'I have a headache.' (C)</p> Signup and view all the answers

<p>Subjective data, objective data, plan, interventions, patient response (B)</p> Signup and view all the answers

<p>Only noting significant deviations from the expected norms using standardized forms (D)</p> Signup and view all the answers

<p>Narrative documentation (C)</p> Signup and view all the answers

<p>A nurse's opinion about a client's condition. (D)</p> Signup and view all the answers

<p>Use clients direct quotes or summarize, making sure to identify that it is from the patient. (A)</p> Signup and view all the answers

<p>Descriptive information of what a nurse observes, hears, palpates, and smells. (C)</p> Signup and view all the answers

<p>Because it is considered falsification of the patient's record which is a criminal penalty. (B)</p> Signup and view all the answers

<p>Ensuring the documentation is accurate, clear and easy to follow (C)</p> Signup and view all the answers

<p>Subjective, Objective, Assessment, Plan (C)</p> Signup and view all the answers

<p>SOAP notes (B)</p> Signup and view all the answers

<p>Rapid information acquisition and transfer (D)</p> Signup and view all the answers

<p>A comprehensive body system review (D)</p> Signup and view all the answers

<p>To act as a quick reference for organizing patient care (B)</p> Signup and view all the answers

<p>As soon as the patient is admitted (A)</p> Signup and view all the answers

<p>Having a second person listen in on the telephone (D)</p> Signup and view all the answers

<p>Telephone order read back (D)</p> Signup and view all the answers

<p>For quality improvement. (A)</p> Signup and view all the answers

<p>Patient's name and date of birth (B)</p> Signup and view all the answers

<p>Introduction, situation, background, assessment, recommendation, repeat/read back (D)</p> Signup and view all the answers

<p>Hospital-acquired infection (C)</p> Signup and view all the answers

<p>Influenza (B)</p> Signup and view all the answers

<p>Performing a time-out in the operating room (C)</p> Signup and view all the answers

<p>A potential error that was avoided (A)</p> Signup and view all the answers

<p>A 'never event' (C)</p> Signup and view all the answers

The use of technology and computer systems in healthcare to improve patient care, information management, and efficiency.

Personal health information (PHI) should be kept private and protected, respecting patient privacy and confidentiality.

The Health Insurance Portability and Accountability Act (HIPAA) establishes national standards to protect sensitive patient health information.

Providing a detailed summary of a patient's condition, treatment, and care plan to the incoming healthcare provider.

Patient medical records are important for communication, legal documentation, billing, research, and education.

Accurate, timely, clear, complete, and objective.

A professional code of ethics that emphasizes confidentiality and patient rights.

Ethical principles guide healthcare professionals to prioritize patient well-being and respect their privacy.

Any identifying information related to a patient's health, like name, date of birth, social security number, diagnosis, etc.

The principle of keeping patient information confidential, preventing its unauthorized disclosure.

Rules governing how patient data is collected, used, disclosed, and protected.

Information documented by the nurse that reflects the patient's own words about their condition.

Information observed and gathered by the nurse about the patient, using their senses. It's factual and measurable.

Method of documenting patient information using a standardized format, focusing on deviations from the expected norm.

A system for documenting patient care that focuses on problems identified and the interventions taken to address them.

A commonly used format for documenting under POMR, focusing on subjective data, objective data, assessment, and plan of action.

A common format for documenting under POMR, focusing on patient problem, interventions, and evaluation of the interventions.

Factual, accurate, complete, current, and organized.

Notes that record information about the patient's condition and their treatment.

A medical record that summarizes all the patient's past medical history, immunizations, allergies, medications, etc.

The use of shortened forms or symbols to represent words or phrases in medical documentation.

The process of reviewing the patient's records to ensure completeness and accuracy.

A serious, unexpected event that causes severe harm to a client, such as death or severe injury.

A situation where there are too few nurses to provide safe and effective care to patients.

Hostile behavior directed at nurses by other healthcare professionals, such as bullying or intimidation.

A system designed to help staff respond to a fire, ensuring the safety of everyone in the building.

A plan designed to prepare for and respond to emergencies, such as natural disasters or active shooter events.

A type of restraint used to prevent patients from getting out of bed or moving around.

A medication used to calm or sedate a patient, sometimes used as a restraint.

Measures taken to prevent falls, such as grab bars, non-slip mats, and bed alarms.

A method of restraint where a patient is placed in a locked room alone.

A type of restraint used to protect a patient's head during a seizure.

A type of progress note that uses a story-like format to document the patient's care.

A progress note format that focuses on data, action, and response, using a specific format to document patient care.

A progress note format that focuses on the patient's problem, the interventions provided, and the evaluation of the intervention's effectiveness.

A tool used to gather a comprehensive assessment of the patient, including their medical history, psychosocial factors, and current health status.

A concise summary of the patient's current status, including key information about their diagnosis, treatment, and progress.

Standardized plans of care that outline evidence-based interventions and expected outcomes for specific conditions or needs.

A document that summarizes the patient's hospital stay and outlines their discharge plan, including medications, follow-up appointments, and community resources.

A document used to record unexpected events or occurrences that may deviate from routine patient care.

The use of two identifiers, such as name and date of birth, to ensure the accurate identification of a patient.

A structured communication tool that promotes effective communication among healthcare providers, particularly during handoffs and transitions in care.

A method of ensuring medication safety by meticulously documenting the medication, dose, date, and time of administration.

Infections acquired in a healthcare setting, including central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and ventilator-associated pneumonia (VAP).

A process used to ensure the correct surgical procedure is performed on the correct patient and at the correct site, involving a series of safety checks and a time-out before surgery.

An event that could have caused harm to a patient but was avoided due to timely intervention or mitigation.

An unexpected event that occurred with or without patient injury but had the potential to cause harm.