NURS 305 Exam 3 Questions with Verified Solutions Latest Version 2025 Already Passed
Health Insurance Portability and Accountability Act (HIPAA) of 1996 - Answers was the first federal
legislation to provide protection for patient records; it governs all areas of patient information and
management of that information.
requires providers to notify patients of privacy policies and to obtain written acknowledgment from
patients indicating they received this information.
the Privacy Rule requires disclosure or requests regarding health information are limited to the specific
information required for a particular purpose
For example, if you need a patients phone number to reschedule an appointment, access to the health
record is limited solely to telephone information.
protected health information (PHI) - Answers under HIPAA is the Security Rule, which specifies
administrative, physical, and technical safeguards for 18 specific elements of ______ in electronic form
Nurses are permitted to use health records for data gathering, research, or continuing education as long
as records are used as specified and permission is granted from an - Answers Institutional Review Board
or appropriate administrative department.
Personal health information - Answers is individually identifiable information relating to an individual's
past, present, or future health status that is created, collected, transmitted, or maintained by a HIPAA-
covered entity in relation to the provision of health care, payment for health care services, or use in
health care operations
Failure to adhere to HIPAA can result in - Answers civil and criminal penalties for health care agencies
and providers. civil penalties can result in minimal fines of $100 per violation and maximum fines of
$50,000 violation with an annual maximum of $1.5 million
fax security - Answers Always use a cover letter.
To prevent numbers from being misdialed, use saved speed-dial numbers for frequently used fax
recipients. Check those numbers regularly.
,For any new recipient, verify the number with a test fax before sending PHI.
Follow policies for what to do if a fax is sent to the wrong number.
Set up fax machines to never save copies of faxes sent or received.
Make sure that faxes containing PHI are promptly delivered to the intended recipient.
Follow agency policies for storing, copying, and disposing of faxes containing PHI.
Use a fax machine designated exclusively for PHI, and keep it separate from other fax machines.
require health care institutions to monitor and evaluate the quality and appropriateness of patient care -
Answers The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS)
Audits of health records offer information on - Answers recurrent health care problems, specific patient
incidents, and whether health care providers follow standards of care.
help to identify areas for improvement and staff development.
your documentation needs to conform to the standards of the National Committee for Quality
Assurance (NCQA) and accrediting bodies such as TJC to maintain institutional - Answers accreditation
and to minimize liability.
Current documentation standards require that all patients admitted to a health care agency be assessed
for - Answers Physical, psychosocial, environmental, self-care, spiritual, cultural , knowledge level, and
discharge planning needs
health care documentation is affected by standards from - Answers HIPAA, state and federal regulatory
agencies, the Department of Justice, and CMS.
Quality nursing documentation has five important characteristics: - Answers factual
accurate
current
, organized
complete
Tips: Stick to the facts. Write in short sentences. Use simple, short words. Avoid the use of jargon or
abbreviations.
A factual record contains - Answers clear descriptive, objective information about what a nurse
observes, hears, palpates, and smells.
Avoid vague terms such as appears, seems, or apparently.
The only subjective data included in the record are statements made by a patient.
Accurate record contains - Answers Using exact measurements establishes accuracy and helps you
determine whether a patient's condition has changed in positive or negative way.
Documentation of concise data is clear and easy to understand. Avoid using unnecessary words and
irrelevant detail.
Appropriate Use of Abbreviations in Health Care Documentation - Answers Use abbreviations carefully
to avoid misinterpretation and promote patient safety.
Do not use abbreviations
U
IU
QD or QOD
Trailing zero, lack of leading zero
MS or MSO4 or MgSO4
All health care record entries should be - Answers dated and timed, and the author of each entry must
be clearly identified
Document the following activities or findings at the time of occurrence: - Answers Vital signs
Health Insurance Portability and Accountability Act (HIPAA) of 1996 - Answers was the first federal
legislation to provide protection for patient records; it governs all areas of patient information and
management of that information.
requires providers to notify patients of privacy policies and to obtain written acknowledgment from
patients indicating they received this information.
the Privacy Rule requires disclosure or requests regarding health information are limited to the specific
information required for a particular purpose
For example, if you need a patients phone number to reschedule an appointment, access to the health
record is limited solely to telephone information.
protected health information (PHI) - Answers under HIPAA is the Security Rule, which specifies
administrative, physical, and technical safeguards for 18 specific elements of ______ in electronic form
Nurses are permitted to use health records for data gathering, research, or continuing education as long
as records are used as specified and permission is granted from an - Answers Institutional Review Board
or appropriate administrative department.
Personal health information - Answers is individually identifiable information relating to an individual's
past, present, or future health status that is created, collected, transmitted, or maintained by a HIPAA-
covered entity in relation to the provision of health care, payment for health care services, or use in
health care operations
Failure to adhere to HIPAA can result in - Answers civil and criminal penalties for health care agencies
and providers. civil penalties can result in minimal fines of $100 per violation and maximum fines of
$50,000 violation with an annual maximum of $1.5 million
fax security - Answers Always use a cover letter.
To prevent numbers from being misdialed, use saved speed-dial numbers for frequently used fax
recipients. Check those numbers regularly.
,For any new recipient, verify the number with a test fax before sending PHI.
Follow policies for what to do if a fax is sent to the wrong number.
Set up fax machines to never save copies of faxes sent or received.
Make sure that faxes containing PHI are promptly delivered to the intended recipient.
Follow agency policies for storing, copying, and disposing of faxes containing PHI.
Use a fax machine designated exclusively for PHI, and keep it separate from other fax machines.
require health care institutions to monitor and evaluate the quality and appropriateness of patient care -
Answers The Joint Commission (TJC) and the Centers for Medicare and Medicaid Services (CMS)
Audits of health records offer information on - Answers recurrent health care problems, specific patient
incidents, and whether health care providers follow standards of care.
help to identify areas for improvement and staff development.
your documentation needs to conform to the standards of the National Committee for Quality
Assurance (NCQA) and accrediting bodies such as TJC to maintain institutional - Answers accreditation
and to minimize liability.
Current documentation standards require that all patients admitted to a health care agency be assessed
for - Answers Physical, psychosocial, environmental, self-care, spiritual, cultural , knowledge level, and
discharge planning needs
health care documentation is affected by standards from - Answers HIPAA, state and federal regulatory
agencies, the Department of Justice, and CMS.
Quality nursing documentation has five important characteristics: - Answers factual
accurate
current
, organized
complete
Tips: Stick to the facts. Write in short sentences. Use simple, short words. Avoid the use of jargon or
abbreviations.
A factual record contains - Answers clear descriptive, objective information about what a nurse
observes, hears, palpates, and smells.
Avoid vague terms such as appears, seems, or apparently.
The only subjective data included in the record are statements made by a patient.
Accurate record contains - Answers Using exact measurements establishes accuracy and helps you
determine whether a patient's condition has changed in positive or negative way.
Documentation of concise data is clear and easy to understand. Avoid using unnecessary words and
irrelevant detail.
Appropriate Use of Abbreviations in Health Care Documentation - Answers Use abbreviations carefully
to avoid misinterpretation and promote patient safety.
Do not use abbreviations
U
IU
QD or QOD
Trailing zero, lack of leading zero
MS or MSO4 or MgSO4
All health care record entries should be - Answers dated and timed, and the author of each entry must
be clearly identified
Document the following activities or findings at the time of occurrence: - Answers Vital signs
