Chapter1 Flashcards
(41 cards)
What is the legal record of care called?
The medical record
The medical record is confidential, permanent, and admissible in court.
Who can access a client’s medical record?
Only health care providers directly involved in the client’s care
This ensures confidentiality and privacy.
What is the primary purpose of documentation in nursing?
To reflect the nursing process and provide continuity of care
Documentation is also essential for legal, financial, and educational purposes.
What are the elements of documentation that nurses must ensure?
- Factual
- Accurate and concise
- Complete and current
- Organized
Each element contributes to the quality of documentation.
What should nurses include when documenting subjective data?
Direct quotes or summarized information identified as the client’s statement
Subjective data should be supported by objective data.
What is the requirement for documentation to be considered accurate?
Document facts precisely without interpretations
This includes avoiding unnecessary words and irrelevant details.
What should each entry in a medical record begin with?
The date and time
This is important for legal and chronological accuracy.
What is the purpose of incident reports?
To document accidents or unusual occurrences and contribute to quality improvement
Incident reports help prevent future incidents.
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
It ensures the confidentiality of health information.
What is required for a patient to give informed consent?
- Disclosure
- Comprehension
- Competence
Each element is crucial for legal and ethical compliance.
What is the difference between criminal law and civil law?
Criminal law seeks to punish offenses against society, while civil law resolves disputes between individuals
Criminal law involves state prosecution; civil law involves private parties.
What is tort law?
A civil wrong inflicted on another person or their belongings
Types of torts include intentional, quasi-intentional, and unintentional torts.
What should nurses do to maintain information security?
- Log off computers
- Never share user IDs or passwords
- Shred printed PHI
These practices help protect patient information.
Fill in the blank: The _______ Rule promotes the use of standard methods to maintain the privacy of protected health information.
Privacy
It is a major component of HIPAA.
What is the role of the nurse in the informed consent process?
- Ensure provider gave necessary information
- Confirm client understood the information
- Document questions and clarifications
The nurse acts as a witness and facilitator in the process.
True or False: Nurses can share patient information with any staff member.
False
Only those directly involved in the patient’s care can access their information.
What are the advantages of electronic health records?
- Standardization
- Accuracy
- Confidentiality
- Easy access for multiple users
These benefits enhance patient care and information management.
What type of law is based on the U.S. Constitution?
Constitutional Law
It establishes the powers and limits of the government branches.
What is the purpose of the documentation formats like flow charts?
To show trends in assessments such as vital signs
They help visualize patient data over time.
What must be documented during a telephone report?
- Name of the person who made the call
- To whom the information was given
- Time and content of the message
Accurate documentation is essential for continuity of care.
What constitutes negligence in documentation?
Failure to properly document can constitute negligence and be the basis for tort liability.
Insufficient or inaccurate assessments and documentation can hinder proper diagnosis and treatment and result in injury to the client.
What is an incident report?
An agency record of an accident or unusual occurrence used to document facts and contribute to statistical data.
Also known as an unusual occurrence report.
What are the purposes of incident reports?
To make facts available to personnel, contribute to statistical data, and help prevent future incidents.
All accidents are usually reported on incident forms.
What is a ‘near miss’?
An error committed that did not harm the client due to intervention or luck.
Examples include when a nurse administers medication intended for another client but the client realizes the mistake.
