Answers Study Guide
A patient with coronary artery disease is admitted to the hospital. An electronic health record
(EHR) is generated for the patient. Which information will be present in the EHR? Select all that
apply.
1
Medications
2
Laboratory data
3
Educational qualifications
4
Financial background
5
Medical and surgical history - correct answer ✔✔The electronic health record (EHR) is a
computerized record of protected health information (PHI). It includes information such as
patient demographics, progress notes, problems and medications, vital signs, medical history,
immunizations, and laboratory and radiology reports. The educational qualifications of the
patient are not included in EHR. Similarly, the financial background of the patient is not
mentioned in the EHR.
Text Reference - p. 10
At the end of a very long day involving the death of a patient, the nurse uses her social media
account to share her experience and find some support. According to the Health Insurance
Portability and Accountability Act (HIPAA) which posting would be acceptable?
1
"One of my favorite patients died today from pancreatic cancer. It was so difficult because he
was only 27. So young."
, 2
"It was a very difficult day for me due to the death of one of my favorite patients."
3
"My shift at Affinity General was so hard today when one of my long-term patients died."
4
"It is so sad when a young, healthy guy like the one I have been taking care of dies from cancer."
- correct answer ✔✔HIPAA prohibits the sharing of any health information which could
potentially identify a patient. Stating that the nurse had a difficult day due to the death of a
favorite patient does not contain any personally identifying information and generally would not
be considered a violation. Sharing any information pertaining to location (Affinity Hospital), age
(27), or diagnosis (cancer) could aid in identification of the individual and is thus prohibited by
HIPAA standards.
Text Reference - p. 4
A nurse understands that it is very important to identify the patient accurately before any
patient-related activity is performed. What measures should the nurse take to improve the
accuracy of patient identification?
1
Ask the patient his or her name repeatedly.
2
Assign a number to the patient and do not use personal names.
3
Use at least two ways of identifying the patient, including full name and date of birth.
4
Ask another nurse to keep records of the same patient as a backup. - correct answer ✔✔The
best way to improve the accuracy of patient identification is to use at least two ways to identify
patients. The nurse can use information such as the patient's full name and date of birth or full
name and birth city. Asking the patient to repeat his or her name is not practical and will not
serve the purpose. Similarly, giving only numbers to patients may create confusion. Asking the
other nurse to keep a backup will only increase workload and is not practical.