Fundamentals of Nursing Informatics and Documentation Review Questions and Answers 2023

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documentation - anything written or printed within a patient record, which may be paper, electronic, or a combination of both formats what is important about the information you communicate about yo... ur patient care? - it reflects the type and frequency of care and provides accountability for each health care team member's care what does quality nursing care depend on? - your ability to communicate effectively verbally and in writing, you are held accountable for the accuracy of documentation you enter into the patient's record what does the TJC and CMS require for health care institutions? - monitor and ovulate the quality and appropriateness of patient care Nurse are ___and ______ obligated to keep information about patient's confidential - legally and ethically who can you not disclose information about a patient's status? - other patients, family members (unless granted by the patient, or health care staff not involved in their care what must you get to release of medical information from a patient? - written permission H.I.P.A.A standards for - The Health Insurance Portability and Accountability Act what does HIPAA do? - provides legislation to protect patient privacy for health information, governs all area of health information management, including reimbursement, medical records, coding, security, and patient record management what are providers required to do for patients regarding HIPAA? - notify patients of their privacy policy and make a reasonable effort to get written acknowledgement of this notification how must you review the medical record of a patient? - only for information needed to provide safe, efficient care that is appropriate to your patient How will you use patient information during student clinical practice? - do not include patient identifiers such as room number, date of birth, medical record number, or other identifiable demographic information what are some examples of things you record based on standards or policies - how often you record a nursing assessment or a patient's level of pain [Show More]

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