Chapter 3 exam review 1. What is the best time to document nursing care- 2. What
ID: 246509 • Letter: C
Question
Chapter 3 exam review 1. What is the best time to document nursing care- 2. What are the guidelines for documentation- 3. Example of a HIPPA violation- 4. Example of how a nurse adheres to the concept of confidentiality- 5. What is an ethical responsibility of the nurse- 6. True or false- patient care partnership demand that information be kept confidential. 7. How do you correct an error 8. What is an incident report form- 9. What is the purpose of logging off when using electronic documentation- 10. What are the guidelines for filling out an incident report 11. What does a therapeutic communication accomplish- 12. What are standards of care-
Explanation / Answer
Complete the document as soon as possible. If you are administrating medications, documentation should be done immediately after this. Do not wait for completing medications to all patients. It is adviced to complete history and physical examination within 24 hours after the admission of the patient. Documentation is factual, objective and clienty centered- It should be clear, accurate and relevant- It should be complete including Nursing Actions and Client Responses - It should be updated as soon as possible after the intervention or interaction occured- It should be organized, logical and sequential ( Information should be in chronological manner, so that nursing decisions and actions and client responses to actions are evident One of the examples of HIPAA violation is sharing confidential information to other person without patient consent. Another example is, if a physiotherapist visits the ward to see his patient , but he looks other patients file which is not relevant to him, it is against HIPAA policies. A nurse cannot share an information of the patient without patients consent- She cannot reveal patients confidential information to her friends, roommates or colleagues - If a patient relative, friends and family members are concerned with patient diagnosis never reveal anything without patient consent. Keep all medical records safely. Medical records should not be easily accessible to others. Do not share patient information to friends/ colleagues who are working at different departments but same hospital 7) To correct an error, strike the point with a single line , do not make an error to be complicated by rubbing or scratching
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