NUR 304 Chapter 16
- documentation
Answer written, legal record of all pertinent interventions with the patient
- assessments, diagnoses, plans, interventions, and evaluations
- patient record
Answer a compilation of a patient's health information; the patient record is the only permanent legal document that details the nurse's interactions with the patient
- The nurse's best defense if a patient or patient surrogate alleges nursing negligence
- documentation
Answer aims
complete, accurate, concise, cur- rent, factual, and organized data communicated in a timely and confidential manner to facilitate care coordination and serve as a legal document
- Content
- Timing
- Format
- Accountability
- Confidentiality
Use the 24-hour cycle military clock for documenting times
- confidential
Answer All information about patients is considered private or
, whether written on paper, saved on a computer, or spoken aloud; this 1 / 3
includes
- Names and all identifiers
- Reason the patient is sick
- Treatments received
- Information about past health conditions
5. HIPAA
Answer rule that protects the privacy of individually indentifiable health information
- security
Answer rule that sets national standards for the security of electronic protected health information
- breach notification
Answer rule that requires covered entities and business associates to provide notification following a breach of unsecured protected health information
- patient safety
- rule protects identifiable information being used to analyze patient safety events and
Answer confidentiality provisions of the
improves patient safety
- false
T/F
Answer according to HIPAA, patients have the right to revise the information in their health record
- communication
Answer a purpose of patient records; help health care professionals from different disciplines (who 2 / 3
interact with the patient at different times) communicate with one another
- Fosters continuity of care
- read back
Answer the act in which the recipient reads back the verbal message as he or she heard and interpreted it; the person giving the order then confirms that such recording and interpretation of the order is correct
- source-oriented
Answer which type of record/documentation? a paper format in which each health care group keeps data on its own separate form
- An advantage = each discipline can easily find and chart pertinent data
- Disadvantage = data are fragmented, making it difficult to track problems chrono- logically
- Includes progress notes and narrative notes
with input from different groups of professionals
- problem-oriented
Answer which type of record/documentation? a paper record used in some health agencies, organized around a patient's problems rather than around sources of information; all health care professionals record information on the same forms
- Advantage = the entire health care team works together in identifying a master list of patient
- SOAP format
problems and contributes collaboratively to the plan of care
- intervention, evaluation, response
Answer what does the IER in SOAPIER stand for?
- PIE charting
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