Chapter 26 Informatics and Documentation

Chapter 26: Informatics and Documentation MULTIPLE CHOICE 1. A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a. Reading the patient’s plan of care b. Reviewing the patient’s medical record c. Sharing patient information with another student d. Documenting medication administered to the patient ANS: C When you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standards have been violated, causing the preceptor to intervene. You can review your patients’ medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient’s medical record and plan of care. You do not share this information with classmates and you do not access the medical records of other patients on the unit. DIF: Apply (application) OBJ: Identify ways to maintain confidentiality of electronic and written records. TOP: Evaluation MSC: Management of Care 2. A nurse exchanges information with the oncoming nurse about a patient’s care. Which action did the nurse complete? a. A verbal report b. An electronic record entry c. A referral d. An acuity rating ANS: A Whether the transfer of patient information occurs through verbal reports, electronic or written documents, you need to follow some basic principles. Reports are exchanges of information among caregivers. A patient’s electronic medical record or chart is a confidential, permanent legal documentation of information relevant to a patient’s health care. Nurses document referrals (arrangements for the services of another care provider). Nurses use acuity ratings to determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours. DIF: Understand (comprehension) OBJ: Describe the different methods used in record keeping. TOP: Communication and Documentation MSC: Management of Care 3. A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking? a. Determining the degree to which standards of care are met by reviewing patients’ health records Realizing that care not documented in patients’ health records still qualifies as care provided c. Basing reimbursement upon the diagnosis-related groups documented in patients’ records d. Comparing data in patients’ records to determine whether a new treatment had better outcomes than the standard treatment b. ANS: A The auditing and monitoring of patients’ health records involve nurses periodically auditing records to determine the degree to which standards of care are met and identifying areas needing improvement and staff development. The mistakes in documentation that commonly result in malpractice include failing to record nursing actions; this is the aspect of legal documentation. The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient’s recorded findings to determine whether the new method was more effective than the standard protocol. Data analysis contributes to evidence-based nursing practice and quality health care. DIF: Analyze (analysis) OBJ: Identify purposes of a health care record. TOP: Communication and Documentation MSC: Management of Care 4. After providing care, a nurse charts in the patient’s record. Which entry will the nurse document? a. Appears restless when sitting in the chair. b. Drank adequate amounts of water. c. Apparently is asleep with eyes closed. d. Skin pale and cool. ANS: D A factual record contains descriptive, objective information about what a nurse observes, hears, palpates, and smells. Objective data is obtained through direct observation and measurement (skin pale and cool). For example, “B/P 80/50, patient diaphoretic, heart rate 102 and regular.” Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. Use of exact measurements establishes accuracy. For example, a description such as “Intake, 360 mL of water” is more accurate than “Patient drank an adequate amount of fluid.” DIF: Apply (application) OBJ: Describe five quality guidelines for documentation. TOP: Communication and Documentation MSC: Management of Care 5. A nurse has provided care to a patient. Which entry should the nurse document in the patient’s record? a. Status unchanged, doing well. b. Patient seems to be in pain and states, “I feel uncomfortable.” c. Left knee incision 1 inch in length without redness, drainage, or edema. d. Patient is hard to care for and refuses all treatments and medications. Family is present. ANS: C Use of exact measurements establishes accuracy. Charting that an abdominal wound is “approximated, 5 cm in length without redness, drainage, or edema,” is more descriptive than “large abdominal incision healing well.” Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as “status unchanged” or “had good day.” It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. “Patient is hard to care for” is a personal opinion and should be avoided. It is also a critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, “refuses all treatments and medications.” DIF: Apply (application) OBJ: Describe five quality guidelines for documentation. TOP: Communication and Documentation MSC: Basic Care and Comfort 6. Which action by a novice nurse will cause the preceptor to provide follow up instructions? a. Documents descriptively. b. Charts consecutively on every other line. c. Ends each entry with signature and title. d. Uses quotations to note patients’ exact words. ANS: B Chart consecutively, line by line (not every other line); every other line is incorrect and must be corrected by the preceptor. If space is left, draw a line horizontally through it, and place your signature and credentials at the end. Every other line should not be left blank. All the other behaviors are correct and need no follow-up. Documenting should be as descriptive as possible. End each entry with signature and title/credentials. When recording subjective data, document a patient’s exact words within quotation marks whenever possible. DIF: Apply (application) OBJ: Discuss legal guidelines for documentation. TOP: Communication and Documentation MSC: Management of Care 7. Which action can the nurse take legally when charting on a patient’s record? a. Charts in a legible manner. b. States the patient is belligerent. c. Writes entry for another nurse. d. Uses correction fluid to correct error. ANS: A Record all entries legibly. Do not write personal opinions (belligerent). Enter only objective and factual observations of patient’s behavior; quote all patient comments. Do not erase, apply correction fluid, or scratch out errors made while recording. Chart only for yourself. DIF: Understand (comprehension) OBJ: Discuss legal guidelines for documentation. TOP: Communication and Documentation MSC: Management of Care 8. A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse access? a. Electronic medical record b. Electronic health record c. Electronic charting record d. Electronic problem record ANS: B The term electronic health record/EHR is increasingly used to refer to a longitudinal (lifetime) record of all health care encounters for an individual patient by linking all patient data from previous health encounters. An electronic medical record (EMR ) is the legal record that describes a single encounter or visit created in hospitals and outpatient health care settings that is the source of data for the EHR. There are no such terms as electronic charting record or electronic problem record that record the lifetime information of a patient. DIF: Understand (comprehension) OBJ: Describe the different methods used in record keeping. TOP: Communication and Documentation MSC: Management of Care 9. A nurse has instructed the patient regarding the proper use of crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the “I” in PIE charting? a. Patient went up and down stairs b. Demonstrated use of crutches c. Used crutches with no difficulties d. Deficient knowledge related to never using crutches ANS: B A second progress note method is the PIE format. The narrative note includes P—Nursing diagnosis, I—Intervention, and E—Evaluation. The intervention is “Demonstrated use of crutches.” “Patient went up and down stairs” and “Used crutches with no difficulties” are examples of E. “Deficient knowledge regarding crutches” is P. DIF: Apply (application) OBJ: Describe the different methods used in record keeping. TOP: Communication and Documentation MSC: Basic Care and Comfort 10. A nurse wants to find the daily weights of a hospitalized patient. Which resource will the nurse consult? a. Database b. Progress notes c. Patient care summary d. Graphic record and flow sheet ANS: D Within a computerized documentation system, flow sheets and graphic records allow you to quickly and easily enter assessment data about a patient, such as vital signs, admission and or daily weights, and percentage of meals eaten. In the problem-oriented medical record, the database section contains all available assessment information pertaining to the patient (e.g., history and physical examination, nursing admission history and ongoing assessment, physical therapy assessment, laboratory reports, and radiologic test results). Many computerized documentation systems have the ability to generate a patient care summary document that you review and sometimes print for each patient at the beginning and/or end of each shift; it includes information such as basic demographic data, health care provider’s name, primary medical diagnosis, and current orders. Health care team members monitor and record the progress made toward resolving a patient’s problems in progress notes. DIF: Apply (application) OBJ: Discuss the advantages of standardized documentation forms. TOP: Communication and Documentation MSC: Basic Care and Comfort 11. A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do? a. Add this data to the problem list. b. Focus chart using the DAR format. c. Document the variance in the patient’s record. d. Report a positive variance in the next interdisciplinary team meeting. ANS: C A variance occurs when the activities on the critical pathway are not completed as predicted or the patient does not meet expected outcomes. An example of a negative variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early). When a nurse is using the problem-oriented medical record, after analyzing data, health care team members identify problems and make a single problem list. A third format used for notes within a POMR is focus charting. It involves the use of DAR notes, which include D—Data (both subjective and objective), A—Action or nursing intervention, and R—Response of the patient (i.e., evaluation of effectiveness). DIF: Apply (application) OBJ: Discuss the relationship between documentation and financial reimbursement for health care. TOP: Communication and Documentation MSC: Management of Care 12. A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient? a. Upon admission b. Right before discharge c. After the congestion is treated d. When the primary care provider writes the order ANS: A Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning. After the congestion is treated is also too late for discharge planning. Usually the primary care provider writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be needed for discharge. By identifying discharge needs early, nursing and other health care professionals begin planning for discharge to the appropriate level of care, which sometimes includes support services such as home care and equipment needs. DIF: Apply (application) OBJ: Identify elements to include when documenting a patient’s discharge plan. TOP: Planning MSC: Basic Care and Comfort 13. A patient is being discharged home. Which information should the nurse include? a. Acuity level b. Community resources c. Standardized care plan d. Signature for verbal order ANS: B Discharge documentation includes medications, diet, community resources, follow-up care, and who to contact in case of an emergency or for questions. A patient’s acuity level, usually determined by a computer program, is based on the types and numbers of nursing interventions (e.g., intravenous [IV] therapy, wound care, or ambulation assistance) required over a 24-hour period. Many computerized documentation systems include standardized care plans or clinical practice guidelines (CPGs) to facilitate the creation and documentation of a nursing and or interprofessional plan of care. Each CPG facilitates safe and consistent care for an identified problem by describing or listing institutional standards and evidence-based guidelines that are easily accessed and included in a patient’s electronic health record. Verbal orders occur when a health care provider gives therapeutic orde rs to a registered nurse while they are standing in proximity to one another. DIF: Understand (comprehension) OBJ: Identify elements to include when documenting a patient’s discharge plan. TOP: Communication and Documentation MSC: Management of Care 14. A nurse developed the following discharge summary sheet. Which critical information should the nurse add? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge a. Clinical decision support system b. Admission nursing history c. Mode of transportation d. SOAP notes ANS: C List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. Clinical decision support systems (CDSSs) are computerized programs used within the health care setting, to aid and support clinical decision making. The knowledge base within a CDSS contains rules and logic statements that link information required for clinical decisions in order to generate tailored recommendations for individual patients that are presented to nurses as alerts, warnings, or other information for consideration. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style. DIF: Understand (comprehension) OBJ: Identify elements to include when documenting a patient’s discharge plan. TOP: Communication and Documentation MSC: Management of Care 15. A home health nurse is preparing for an initial home visit. Which information should be included in the patient’s home care medical record? a. Nursing process form b. Step-by-step skills manual c. A list of possible procedures d. Reports to third-party payers ANS: D Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third-party payers. An interprofessional plan of care is used rather than a nursing process form. A step-by-step skills manual and a list of possible procedures are not included in the record. DIF: Understand (comprehension) OBJ: Identify important aspects of home care and long-term care documentation. TOP: Planning MSC: Management of Care 16. A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing? a. A minimum data set b. An admission assessment and acuity level c. A focused assessment/specific body system d. An intake assessment form and auditing phase ANS: A The Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and the Care Area Assessment (CAA), is the data set that is federally mandated for use in long-term care facilities by CMS. MDS assessment forms are completed upon admission, and then periodically, within specific guidelines and time frames for all residents in certified nursing homes. The MDS also determines the reimbursement level under the prospective payment system. A focused assessment is limited to a specific body system. An admission assessment and acuity level is performed in the hospital. An intake form is for home health. There is no such thing as an auditing phase in an assessment intake. DIF: Understand (comprehension) OBJ: Identify important aspects of home care and long-term care documentation. TOP: Communication and Documentation MSC: Management of Care 17. A nurse is charting. Which event is critical for the nurse to document? a. The patient had a good day with no complaints. b. The family is demanding and argumentative. c. The patient received a pain medication. d. The family is poor and had to go on welfare. ANS: C Nursing interventions and treatments (e.g., medication administration) must be documented. Avoid using generalized, empty phrases such as “status unchanged” or “had good day.” Do not document retaliatory or critical comments about a patient, like demanding and argumentative. Family is poor is not critical information to chart. DIF: Apply (application) OBJ: Describe five quality guidelines for documentation. TOP: Communication and Documentation MSC: Basic Care and Comfort 18. A nurse is completing an Outcome and Assessment Information Set (OASIS) data set on a patient. The nurse works in which area of patient care? a. Home health b. Intensive care unit c. Skilled nursing facility d. Long-term care facility ANS: A Nurses use two different data sets to document the clinical assessments and care provided in the home care setting, the Outcome and Assessment Information Set (OASIS), and the Omaha System. The intensive care unit does not use the OASIS data set. The long-term health care setting includes skilled nursing facilities (SNFs) in which patients receive 24-hour day care. DIF: Understand (comprehension) OBJ: Identify important aspects of home care and long-term care documentation. TOP: Communication and Documentation MSC: Management of Care 19. A nurse is preparing to document a patient who has reported chest pain. Which information provided by the patient is critical for the nurse to include? a. “My family doesn’t believe I’m in pain.” b. Pupils equal and reactive to light. c. Had poor results from the pain medication. d. Reports sharp pain of 8 on a scale of 1 to 10. ANS: D You need to ensure the information within a recorded entry or a report is complete, containing appropriate and essential information (pain of 8). Document subjective and objective assessment. While pupils equal and reactive to light is data, it does not relate to the chest pain; this information would be critical for a head injury. Derogatory or inappropriate comments about the patient or family is not appropriate. This kind of language can be used as evidence for nonprofessional behavior or poor quality of care. Avoid using generalized, empty phrases like “poor results.” Use complete, concise descriptions. DIF: Apply (application) OBJ: Discuss legal guidelines for documentation. TOP: Communication and Documentation MSC: Basic Care and Comfort 20. Which action will the nurse take when taking a telephone order? a. Print out a copy of the order once entered into the electronic health record. b. Read back the order as written to the health care provider for verification. c. Ask that another registered nurse listen to the call over an extension line. d. Verify that the health care provider will write the order within 24 hours. ANS: B A read back of a telephone order is required and should contain all pertinent information so that verification can be secured. None of the other options provide verification of the details related to the order itself. DIF: Apply (application) OBJ: Discuss legal guidelines for documentation. TOP: Communication and Documentation MSC: Management of Care 21. A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document? a. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back. b. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back. c. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back. d. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN. ANS: C The nurse receiving a TO or VO enters the complete order into the computer using the computerized provider order entry (CPOE) software or writes it out on a physician’s order sheet for entry in the computer as soon as possible. After you have taken the order, read the order back, using the “read back” process, and document that you did this to provide evidence that the information received (such as call back instructions and/or therapeutic orders) was verified with the provider. An example follows: “10/16/2015 (08:15), Change IV fluid to Lactated Ringers with Potassium 20 mEq/L to run at 125 mL/hr. TO: Dr. Knight/J. Woods, RN, read back.” VO stands for verbal order, not telephone order. The health care provider’s name and read back must be included in the chart entry. DIF: Apply (application) OBJ: Discuss legal guidelines for documentation. TOP: Communication and Documentation MSC: Management of Care 22. A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up? a. To be proficient in informatics, a nurse should be able to discover, retrieve, and b. c. d. use information in practice. A nurse needs to know how to find, evaluate, and use information effectively. If a nurse has computer competency, the nurse is competent in informatics. Nursing informatics is a recognized specialty area of nursing practice. ANS: C When the staff make an incorrect statement, then the nurse needs to follow up. Competence in informatics is not the same as computer competency. All the rest are correct information, so the nurse does not need to follow up. To become competent in informatics, you need to be able to use evolving methods of discovering, retrieving, and using information in practice. This means that you learn to recognize when information is needed and have the skills to find, evaluate, and use that information effectively. Nursing informatics is a specialty that integrates the use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research. DIF: Understand (comprehension) OBJ: Discuss the relationship between informatics and quality health care. TOP: Teaching/Learning MSC: Management of Care 23. A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using? a. Clinical decision support system b. Nursing process design c. Critical pathway design d. Computerized provider order entry system ANS: C One design model for Nursing Clinical Information Systems (NCIS) is the protocol or critical pathway design. This design facilitates interdisciplinary management of information because all health care providers use evidence-based protocols or critical pathways to document the care they provide. The knowledge base within a CDSS contains rules and logic statements that link information required for clinical decisions in order to generate tailored recommendations for individual patients, which are presented to nurses as alerts, warnings, or other information for consideration. The nursing process design is the most traditional design for an NCIS. This design organizes documentation within well-established formats such as admission and postoperative assessments, problem lists, care plans, discharge planning instructions, and intervention lists or notes. Computerized provider order entry (CPOE) systems allow health care providers to directly enter orders for patient care into the hospital’s information system. DIF: Understand (comprehension) OBJ: Discuss the relationship between informatics and quality health care. TOP: Communication and Documentation MSC: Management of Care 24. A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take? a. Use the same password all the time. b. Share password with only one other staff member. c. Print out and review computer nursing notes at home. d. Chart on the computer immediately after care is provided. ANS: D To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient’s bedside to facilitate immediate documentation of information as it is collected. A good system requires frequent, random changes in personal passwords to prevent unauthorized persons from tampering with records. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances. You destroy all papers containing personal information immediately after you use them. Taking nursing notes home is a violation of the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality. DIF: Apply (application) TOP: Implementation OBJ: Identify ways to reduce data entry errors. MSC: Management of Care 25. Which entry will require follow-up by the nurse manager? 0800 Patient states, “Fell out of bed.” Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, “Did not pass out.” Assisted back to bed. Nurse call system within reach. Bed monitor on. -------------------Jane More, RN 0810 Notified primary care provider of patient’s status. New orders received. -------------------Jane More, RN 0815 Portable x-ray of L hip taken in room. States, “I feel fine.” -------------------Jane More, RN 0830 Incident report completed and placed on chart. -------------------Jane More, RN a. 0800 b. 0810 c. 0815 d. 0830 ANS: D Do not include any reference to an incident in the medical record; therefore, the nurse manager must follow up. A notation about an incident report in a patient’s medical record makes it easier for a lawyer to argue that the reference makes the incident report part of the medical record and therefore subject to attorney review. When an incident occurs, document an objective description of what happened, what you observed, and the follow-up actions taken, including notification of the patient’s health care provider in the patient’s medical record. Remember to evaluate and document the patient’s response to the incident. DIF: Analyze (analysis) OBJ: Discuss legal guidelines for documentation. TOP: Communication and Documentation MSC: Management of Care 26. A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? a. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, “felt better.” Finally, patient had no complaints. c. Breathing without difficulty. Sitting up in bed watching TV. Had a good day. d. Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours. b. ANS: A Accurately documenting services provided, including the supplies and equipment used in a patient’s care, clarifies the type of treatment a patient received. This documentation also supports accurate and timely reimbursement to a health care agency and/or patient. None of the other options had equipment or supplies listed. Avoid using generalized, empty phrases such as “status unchanged” or “had good day.” Do not enter personal opinions—stating that the patient is cooperative is a personal opinion and should be avoided. “Finally, patient had no complaints” is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care. DIF: Analyze (analysis) OBJ: Discuss the relationship between documentation and financial reimbursement for health care. TOP: Communication and Documentation MSC: Management of Care 27. A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session? a. Home health, long-term care, and hospital nurses’ documentation can affect reimbursement for health care. A clinical information system must be installed by 2014 to obtain health care reimbursement. c. A “near miss” helps determine reimbursement issues for health care. d. HIPAA is the basis for establishing reimbursement for health care. b. ANS: A Nurses’ documentation practices in home health, long-term care, and hospitals can determine reimbursement for health care. A “near miss” is an incident where no property was damaged and no patient or personnel were injured, but given a slight shift in time or position, damage or injury could have easily occurred. A clinical information system (CIS) does not have to be installed by 2014 to obtain reimbursement. CIS programs include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. Diagnosis-related groups (DRGs) are the basis for establishing reimbursement for patient care, not HIPAA. Legislation to protect patient privacy regarding health information is the Health Insurance Portability and Accountability Act (HIPAA). DIF: Understand (comprehension) OBJ: Discuss the relationship between documentation and financial reimbursement for health care. TOP: Teaching/Learning MSC: Management of Care 28. A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe? a. Varied clinical databases b. Reduced errors of omission c. Increased hospital costs d. More time to read charts ANS: B Advantages associated with the nursing information system include reduced errors of omission; better access to information (not more time to read charts); enhanced quality of documentation; reduced, not increased, hospital costs; increased nurse job satisfaction; compliance with requirements of accrediting agencies (e.g., TJC); and development of a common, not varied, clinical database. DIF: Understand (comprehension) OBJ: Describe the advantages of a nursing information system. TOP: Communication and Documentation MSC: Management of Care MULTIPLE RESPONSE 1. Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.) a. Writes the patient’s room number and date of birth on a paper for school. b. Prints/copies material from the patient’s health record for a graded care plan. c. Reviews assigned patient’s record and another unassigned patient’s record. d. Gives a change-of-shift report to the oncoming nurse about the patient. e. Reads the progress notes of assigned patient’s record. f. Discusses patient care with the hospital volunteer. ANS: D, E When you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice. Reading the progress notes of an assigned patient’s record and giving a change-of-shift report to the oncoming nurse about the patient are behaviors that follow HIPAA and confidentiality guidelines. Do not share information with other patients or health care team members who are not caring for a patient. Not only is it unethical to view medical records of other patients, but breaches of confidentiality lead to disciplinary action by employers and dismissal from work or nursing school. To protect patient confidentiality, ensure that written materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information), and never print material from an electronic health record for personal use. DIF: Apply (application) OBJ: Identify ways to maintain confidentiality of electronic and written records. TOP: Communication and Documentation MSC: Management of Care 2. A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.) a. Communication b. Legal documentation c. Reimbursement d. Nursing process e. Research f. Education ANS: A, B, C, E, F A patient’s record is a valuable source of data for all members of the health care team. Its purposes include interdisciplinary communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record. DIF: Understand (comprehension) OBJ: Identify purposes of a health care record. TOP: Communication and Documentation MSC: Management of Care 3. A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.) a. Bypass the firewall. b. Implement an automatic sign-off. c. Create a password with just letters. d. Use a programmed speed-dial key when faxing. e. Impose disciplinary actions for inappropriate access. f. Shred papers containing personal health information (PHI). ANS: B, D, E, F When faxing, use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. An automatic sign-off is a safety mechanism that logs a user off the computer system after a specified period of inactivity. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. All papers containing PHI (e.g., Social Security number, date of birth or age, patient’s name or address) must be destroyed immediately after you use or fax them. Most agencies have shredders or locked receptacles for shredding and incineration. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information and should not be bypassed. DIF: Apply (application) OBJ: Identify ways to reduce data entry errors. TOP: Communication and Documentation MSC: Management of Care MATCHING A nurse is using focused charting referred to as DAR. Match the chart entry to the correct letter of the acronym. a. Applied oxygen, stayed with patient, and instructed to slow breathing. b. Patient states, “feel better,” respirations 16 with O 2 saturations 96%. c. Patient states, “can’t catch my breath and chest hurts.” Confused. 1. D 2. A 3. R 1. ANS: OBJ: TOP: 2. ANS: OBJ: TOP: 3. ANS: OBJ: TOP: C DIF: Apply (application) Describe the different methods used in record keeping. Communication and Documentation A DIF: Apply (application) Describe the different methods used in record keeping. Communication and Documentation B DIF: Apply (application) Describe the different methods used in record keeping. Communication and Documentation MSC: Management of Care MSC: Management of Care MSC: Management of Care