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NUR 304 Chapter 16 Questions and answers 2025
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NUR 304 Chapter 16 Questions and answers 2025
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NUR 304Chapter 16
Questions
and
answers
2025
documentation - answer written, legal record of all pertinent interventions
with the patient - assessments, diagnoses, plans, interventions, and
evaluations
, patient record - answer a compilation of a patient's health information;
the patient record is the only permanent legal document that details the
nurse's interactions with the patient
o The nurse's best defense if a patient or patient surrogate alleges
nursing negligence
documentation - answer _________________ aims: complete, accurate, concise,
current, factual, and organized data communicated in a timely and
confidential manner to facilitate care coordination and serve as a legal
document
o Content
o Timing
Use the 24-hour cycle military clock for documenting times
o Format
o Accountability
o Confidentiality
confidential - answer All information about patients is considered private
or _______________, whether written on paper, saved on a computer, or
spoken aloud; this includes
o Names and all identifiers
o Reason the patient is sick
o Treatments received
o Information about past health conditions
HIPAA - answer rule that protects the privacy of individually indentifiable
health information
security - answer rule that sets national standards for the security of
electronic protected health information
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