Chapter 26: Documentation and Informatics Potter et al.: Fundamentals of Nursing, 9th Edition

1. A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a. The student nurse reads the patient’s plan of care. b. The student nurse reviews the patient’s medical record. c. The student nurse shares patient information with a friend. d. The student nurse documents medication administered to the patient. ANS: C When you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standards have been violated, causing the preceptor to intervene. You can review your patients’ medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient’s medical record and plan of care. You do not share this information with classmates and you do not access the medical records of other patients on the unit. DIF: Apply (application) REF: 360 OBJ: Identify ways to maintain confidentiality of electronic and written records. TOP: Evaluation MSC: Management of Care 2. A nurse exchanges information with the oncoming nurse about a patient’s care. Which action did the nurse complete? a. A verbal report b. An electronic record entry c. A referral d. An acuity rating ANS: A Whether the transfer of patient information occurs through verbal reports, electronic or written documents, you need to follow some basic principles. Reports are exchanges of information among caregivers. A patient’s electronic medical record or chart is a confidential, permanent legal documentation of information relevant to a patient’s health care. Nurses document referrals (arrangements for the services of another care provider). Nurses use acuity ratings to determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours. DIF: Apply (application) REF: 359 OBJ: Describe the different methods used in record keeping. TOP: Communication and Documentation MSC: Management of Care 3. A nurse is auditing and monitoring patients’ health records. Which action is the nurse taking? a. Determining the degree to which standards of care are met by reviewing patients’ health records b. Realizing that care not documented in patients’ health records still qualifies as care provided c. Basing reimbursement upon the diagnosis-related groups documented in patients’ records d. Comparing data in patients’ records to determine whether a new treatment had better outcomes than the standard treatment ANS: A The auditing and monitoring of patients’ health records i