NUFT 204 - Documentation: Ch. 26 (With complete solution)

What are the purposes of the medical record? correct answers 1. communication -one of biggest purposes 2. legal documentation -accurate record is best legal defense 3. reimbursement -used by insurance companies for determining payment 4. research -used for gathering data on health problems, interventions and outcomes 5. education -teaches providers/students about conditions 6. auditing/monitoring -used for quality assurance What do experts believe that implementing EHRs across the health care delivery system will do? correct answers decrease costs and improve quality of patient careDesc Describe how confidentiality is applied to documentation. correct answers 1. all patient information obtained must be kept confidential -this is a legal and ethical obligation 2. must protect records from ALL unauthorized readers -this is a responsibility of the nurse -includes everyone who isn't involved in direct treatment of patient 3. HIPPA requires that disclosures or requests for health info be limited to the minimum necessary What information is considered confidential? correct answers 1. name, address, phone, fax, social security # 2. reason person is sick 3. treatment the patient receives 4. information about past health conditions *this includes all written, spoken, or electronic forms of communication* Note physical security measures that can limit the legal risks of electronic documentation. correct answers 1. placing computers or file servers in restricted areas 2. using privacy filters for computer screens visible to visitors or others without access 3. log off computer before leaving it correct answers 1. communication -one of biggest purposes 2. legal documentation -accurate record is best legal defense 3. reimbursement -used by insurance companies for determining payment 4. research -used for gathering data on health problems, interventions and outcomes 5. education -teaches providers/students about conditions 6. auditing/monitoring -used for quality assurance What do experts believe that implementing EHRs across the health care delivery system will do? correct answers decrease costs and improve quality of patient careDesc Describe how confidentiality is applied to documentation. correct answers 1. all patient information obtained must be kept confidential -this is a legal and ethical obligation 2. must protect records from ALL unauthorized readers -this is a responsibility of the nurse -includes everyone who isn't involved in direct treatment of patient 3. HIPPA requires that disclosures or requests for health info be limited to the minimum necessary What information is considered confidential? correct answers 1. name, address, phone, fax, social security # 2. reason person is sick 3. treatment the patient receives 4. information about past health conditions *this includes all written, spoken, or electronic forms of communication* Note physical security measures that can limit the legal risks of electronic documentation. correct answers 1. placing computers or file servers in restricted areas 2. using privacy filters for computer screens visible to visitors or others without access 3. log off computer before leaving it