Exam 9: Documentation and Confidentiality

Nursing home policy states that a registered nurse must cosign all charts that licensed practical nurses complete. What is the effect of this policy on the registered nurse?

The nurse manager is aware that several patients will be admitted to the unit today. Today's staff includes three registered nurses, two licensed practical nurses, and three unlicensed nursing assistants. Who should the manager expect to assess and document the admitted patient's nursing needs?

The parents of a 17-year-old who is receiving state-funded substance abuse treatment have asked the provider for information about their child. What is the correct action by the health care provider?

A newly licensed nurse complains to the preceptor about the amount of time spent documenting in the medical record. What is the preceptor's best response?

The nurse working in a physician's office recorded assessment data in the wrong patient's medical record about 1 hour ago. How should the nurse correct this error?

The patient demands to see the actual medical record of a hospitalization that occurred 1 year ago. How should the hospital handle this request?

Which statement, made by a staff nurse, would the nurse manager evaluate as evidence of good understanding of the importance of the electronic medical record?

A nurse is preparing information to be distributed at a national conference on AIDS. What should be included regarding mandatory disclosure of AIDS status?

A nurse strongly believes that all newborns should be screened for HIV at birth. Which ethical principle would the nurse cite to support this argument?

A patient requests that records of her hospitalization for treatment of an infection following an abortion be destroyed as soon as she is discharged. What is the likely outcome of this request?

A patient incident occurred on the nursing unit. What should the nurse caring for the patient do in regard to the incident report?

As part of conversion to a new electronic medical record format, a hospital is also instituting charting by exception. The nurse manager would caution staff nurses that charting by exception has which major drawback?

The nursing student began a case study paper by writing, "J.P., a 65-year-old Asian male, was admitted to the intensive care unit at Southwest Hospital." What is the significance of this statement?

The patient brings suit against a health care provider. In which ways would the nurse expect this action will affect the confidentiality of the patient's medical record?

The nurse discussing the Health Insurance Portability and Accountability Act (HIPAA) says, "I am aware that this act changed the way we handle confidential information." What other provisions of this act should the nurse consider?