Deck 9: Documentation and Confidentiality

Question 1

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?

A) It places the RN in the position of endorsing and authenticating the entries made in the charts cosigned.
B) It gives legal proof that the RN was in the facility.
C) It has no legal effect on the RN.
D) It makes the RN personally liable for any subsequent harm that befalls the patient.

Answer 1

It places the RN in the position of endorsing and authenticating the entries made in the charts cosigned.

Question 2

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?

A) "The most important reason we document is to help us communicate the patient's condition to the rest of the health care team."
B) "Since you just took a course in nursing research, you should realize the value of accurate documentation as a source of research data."
C) "We have to document so that charges are clear to third-party payers."
D) "The medical record protects us if a lawsuit is filed."

Answer 2

"The most important reason we document is to help us communicate the patient's condition to the rest of the health care team."

Question 3

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?

A) Black out the error with a marker and enter the new information.
B) Indicate the date and time the correction was made.
C) Indicate the reason the correction is being made by writing "wrong patient chart" along with the new information.
D) Enclose the corrected information in brackets to set it off from the original post.
E) Either initial or sign the correction.

Answer 3

Indicate the date and time the correction was made.
Indicate the reason the correction is being made by writing "wrong patient chart" along with the new information.
Either initial or sign the correction.

Question 4

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

A) Carefully document the completion of an incident report in the nurse's notes.
B) Write a recommendation for future prevention of such incidents in the report.
C) Include only the facts and the nurse's observations in the incident report.
D) Assist the nursing supervisor who will write the report.
E) Include documentation in the medical record about the event that mandated completion of an incident report.

Question 5

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?

A) An anti-fraud and anti-abuse program
B) Establishment of state governments as health care regulators
C) A law preventing portability of health care coverage
D) Tax incentives for preventive care
E) Streamlining of transfer of patient information between insurers and providers

Question 6

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) Refuse the request pursuant to the provision of the common-law duty to disclose.
B) Refuse the request as it is likely to interfere with the treatment plan.
C) Release the information immediately as parents always can receive information on minor children.
D) Release information only if the patient has signed consent to do so.

Question 7

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?

A) It is incomplete, as the date and time of admission should be included.
B) It is a good description of the patient to begin the paper.
C) It violates Health Insurance Portability and Accountability Act regulations.
D) It is incomplete, as the patient's physician's name should be included.

Question 8

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?

A) The confidentiality of the record will remain intact.
B) The patient's attorney will have access to the information in the record.
C) The record loses confidentiality and is discoverable by any interested party.
D) The record will be released to the defendant's attorney.
E) Only the judge will have full access to the medical record.

Question 9

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?

A) It may not provide enough information to support trending of the patient's condition.
B) It does not allow for use of uniform standards.
C) It is not admissible in court because there is not enough background in the documentation.
D) This method takes much more time than narrative charting.

Question 10

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) The record will be sealed.
B) The record will be destroyed.
C) The request will be denied.
D) The record will be given to the patient's attorney.

Question 11

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

A) Deny the demand; the patient has no legal right to this record.
B) Have the patient come to the hospital to review the original record.
C) Send the patient a copy of the medical record by registered mail.
D) Do not comply with this demand unless the patient provides a subpoena for the record.

Question 12

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) Informed consent
B) Confidentiality
C) Beneficence
D) Autonomy

Question 13

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) Every state requires that all sexual contacts of a person diagnosed with AIDS be contacted and treated.
B) AIDS status must be disclosed to any health care provider who has cared for the patient within the last 18 months and to any future health care provider.
C) In general AIDS status is considered confidential.
D) All AIDS cases must be reported to the Centers for Disease Control and Prevention or to the state health department.
E) All babies born in the United States are tested for presence of HIV at birth.

Question 14

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?

A) The nursing assistant
B) The admitting physician
C) A registered nurse
D) A licensed practical or vocational nurse

Question 15

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) "Since nurses are the only ones using this system, I won't have to wait to document anymore."
B) "I'm glad that it will take less time for us to document."
C) "I hope we don't have to keep changing passwords."
D) "They say that our patient care will improve while we are using this system."