NURS 231 Exam 3 Questions With Verified Answers 2024/2025
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NURS 231
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NURS 231
NURS 231 Exam 3 Questions With Verified
Answers 2024/2025
This is the written or electronic legal record of all pertinent interactions with the
patient?
That would be documentation.
What 5 things does documentation require?
assessing, diagnosing, planning, implementing, and evaluating.
A rep...
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NURS 231 Exam 3 Questions With Verified Answers 2024/2025 This is the written or electronic legal record of all pertinent interactions with the patient? That would be documentation. What 5 things does documentation require? assessing, diagnosing, planning, implementing, and evaluating. A repeated phrase by nurses regarding documentation "if it wasn't charted, it wasn't done" a compilation of patient health information is a patient record. This committee specifics that nursing care data related to the patients assessments, nursing diagnoses or patient needs, nursing interventions, and patient outcomes are permanently integrated into the patient record. the joint commission what is the only p ermanent legal document that details the nurses interactions with the patient? The patient record what was the purpose of the ANA's principles for nursing documentation? Essentially helps nurses document better and faster. effective documentation is access ible, accurate, relevant, and consistent; auditable, clear, concise, and complete; legible/readable; thoughtful; timely, contemporaneous, and sequential; reflective of the nursing process; and retrievable on a permanent basis in a nursing -specific manner. who decided this standard? The ANA what information is considered confidential? all information regarding the patient. This includes, any patient identifiers, reasons they are there, assessments and treatments, information about past medical conditions. what examples of breaches in confidentiality? 1. discussing patients in any public area. 2. leaving patient information in a public area. 3. leaving a computer open in a public area. 4. sharing or exposing passwords 5. copying data for yourself. what are way s to prevent data breaches on computers? 1. make sure that screens do not face the public. 2. only send emails on safe wifi 3. request a copier for the unit that you are on and only using that copier. 4. use a disposal container when destroying patient for ms 5. use safe phones 6. verify the fax number before sending the information 7. do not use voice pagers HIPPA states that 1. see and copy their health record. 2. update their health record. 3. get a list of the disclosures that a health care institution h as made independent of disclosures made for the purposes of treatment, payment, and health care operations. 4. request a restriction on certain uses or disclosures. 5. choose how to receive health information. If a health institution wants to release patie nt health information (PHI) for purposes other than treatment, payment, or routine health care operations, the patient must be asked to sign an authorization what are the 3 exceptions for patient health information to be shared without authorization 1. pub lic health activities 2. law enforcement and judicial proceedings 3. deceased people what is an incidental disclosure of PHI and examples? Something that is a byproduct and cannot be stopped or used.... examples: sign -in sheets, confidential conversation b eing overheard, white boards, X -ray boards, or calling names in a waiting room. what is a rule when documenting so that everyone can understand what is being documented? do not use abbrieviations They should NEVER be used when communicating medical information? This includes internal communications, telephone/verbal prescriptions, computer generated labels, labels for drug storage bins, medication administration records, as well as pharmacy and pre scriber computer order entry screens what is important to remember when delegating documentation? their needs to be a clear indication on which things the UAP is documenting and the nurse is documenting. A good rule is to only document what you did. what is the purpose of a patient record? For communication and for the people involved in that patients care to have resources on what is going on with the patient. communication allows health care professionals of different disciplines and shifts the oppo rtunity to see what is going on... it also does what continues continuity of care what are two things that may be in a patient record in relation to orders? diagnostic and therapeutic if a nurse is unsure about an order in the EHR what should the nurse do? check the original order a verbal order must be given for a? and then what should the nurse do back? should be given orally from a physician or nurse practitioner and the nurse should read it back for clarification. list the steps of a verbal order 1. rec ord the orders in the patient's medical record with the letters VO (verbal order). 2. read back the order to verify accuracy of the order. 3. date and note the time the orders were issued
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