Which example may illustrate a breach of confidentiality and security of client information?
The nurse provides information over the phone to the client’s family member who lives in a neighboring state
. The nurse is documenting a variance that has occurred during the shift.
Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act Hipaa?
Which action by the nurse is compliant with the Health Insurance Portability and Accountability Act (HIPAA)? The
nurse calls the health care provider due to changes in the client’s status
. Using the SBAR, the nurse is about to address Recommendation.
Which characteristic of a nurse’s charting will assist most in the avoidance of errors?
PIE charting is a method of recording the client’s progress under the heading of problem, intervention, and evaluation. Which characteristic of a nurse’s charting will assist most n the avoidance of errors?
documentation in timely manner ca help avoid errors
.
Which action by the nurse could result in the accrediting body withdrawing the health agency accreditation?
Which action by the nurse could result in the accrediting body withdrawing the health agency’s accreditation?
Omitting client’s response to nursing interventions.
Which finding from a nursing audit reflects high standards for client safety?
Which finding from a nursing audit reflects high standards for client safety and institutional health care? … Nurses at a
health care facility maintain client records using a method of documentation known as charting by exception (CBE)
.
What are examples of HIPAA violations?
- Stolen/lost laptop.
- Stolen/lost smart phone.
- Stolen/lost USB device.
- Malware incident.
- Ransomware attack.
- Hacking.
- Business associate breach.
- EHR breach.
What are the three rules of HIPAA?
- The Privacy Rule.
- Thee Security Rule.
- The Breach Notification Rule.
What are the six principles of documentation?
- Be clear, legible, concise, contemporaneous, progressive and accurate.
- Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes.
- Meet all necessary medico-legal requirements for documentation.
How do you prevent documentation errors?
Don’t use vague terms, such as “fair” and “normal.” Be clear, concise, and specific in your documentation. Do
correct errors
. Draw a straight line through incorrect entries, and write “error” above them. Initial and date the correction.
What should you do if you make a mistake in charting patient information?
- Don’t obliterate the mistaken entry. …
- Make the correction in a way that preserves the original entry. …
- Identify the reason for the correction. …
- Follow facility policy when adding late information. …
- Never alter words or numbers after you’ve written them. …
- Correct mistakes promptly.
What is the primary purpose of client records?
Explanation: The primary purpose of the client record is
to help health care professionals from different disciplines communicate with one another
.
Which of the following are examples of breaches of client confidentiality?
- Saving sensitive information on an unsecure computer that leaves the data accessible to others.
- Sharing employees’ personal data, like payroll details, bank details, home addresses and medical records.
Which documentation tool will the nurse use to record the clients vital signs every 4 hours?
Which documentation tool will the nurse use to record the client’s vital signs every 4 hours?
A flow sheet
is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics.
How do you write a nursing progress note?
Progress note entries should include
nursing content and evidence of critical thinking
. That is, they should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact and outcome for the particular patient and family involved.
Why is accurate and effective documentation most important?
An accurate written record
detailing all aspects of patient monitoring
is important, not only because it forms an integral part of the of the provision of care or nursing management of the patient, but because it also contributes to the circulation of information amongst the different teams involved in the patient’s …
Which characteristic is the most important indicator of high quality nursing practice?
The personal, compassionate, caring side of a nurse
is the most important indicator of quality nursing care. Considering the individual needs of the clients demonstrates the nurse’s belief in the importance of the client.
