Nursing Documentation and Confidentiality Questions and Answers Rated A+
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Nursing Documentation and
Confidentiality Questions and Answers
Rated A+
What is the purpose of maintaining confidentiality in patient documentation?
To protect patient privacy and ensure that personal health information is not disclosed
without consent.
How should a nurse handle a s...
Nursing Documentation and
Confidentiality Questions and Answers
Rated A+
What is the purpose of maintaining confidentiality in patient documentation?
✔✔ To protect patient privacy and ensure that personal health information is not disclosed
without consent.
How should a nurse handle a situation where a colleague requests access to a patient’s medical
record without a valid reason?
✔✔ Deny access and report the incident to the appropriate authority or supervisor.
What steps should be taken to ensure that documentation is secure in electronic health records
(EHR)?
✔✔ Use strong passwords, regularly update software, and ensure that access is restricted to
authorized personnel only.
What information should be excluded from a patient’s medical record to maintain
confidentiality?
1
,✔✔ Personal identifiers unrelated to medical care, such as social security numbers or personal
opinions, should be excluded.
How should a nurse document a conversation with a patient regarding sensitive information?
✔✔ Record the details of the conversation accurately, including any agreements or disclosures
made, and ensure that the documentation is stored securely.
What should be done if a patient requests to review their own medical record?
✔✔ Follow the established procedure for patient access, ensuring that the request is handled
confidentially and that the patient’s rights are upheld.
How should a nurse document a breach of confidentiality?
✔✔ Document the specifics of the breach, including what information was exposed, how it
happened, and the steps taken to address the breach.
What precautions should be taken when using mobile devices to access patient information?
✔✔ Ensure that devices are encrypted, use secure connections, and restrict access through
passwords or biometric authentication.
2
, How can a nurse ensure that documentation practices comply with legal and ethical standards?
✔✔ Follow organizational policies, stay informed about relevant laws and regulations, and
participate in regular training on confidentiality and documentation.
What should a nurse do if they suspect that a colleague is not maintaining proper confidentiality?
✔✔ Report the concern to a supervisor or appropriate authority for investigation and resolution.
How should a nurse document information that is shared between multiple healthcare providers?
✔✔ Record the details of the information shared, including the date, time, and purpose of the
communication, ensuring all parties involved are noted.
What is the role of encryption in protecting electronic health records?
✔✔ Encryption secures data by converting it into a code that is unreadable without the proper
decryption key, preventing unauthorized access.
How should corrections be made in patient documentation?
✔✔ Cross out the incorrect entry with a single line, add the correct information, and initial and
date the correction.
3
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