Documentation

How do you prevent displaying information on a screen that is viewed by unauthorized users?

make sure display screens do not face public areas. For portable devices, install encryption software that makes information unreadable or inaccessible.

How to prevent sending confidential e-mail messages via public networks such as the internet, where they can be read by unauthorized users

use encryption software when sending e-mail over public networks.

how to prevent breach when sharing printers among units with differing functions and information

request that your unit have a separate printer not shared with another unit.

How do you properly discard copies of patient health information in trash cans adjacent to copiers?

use secure disposal containers (similar to mail boxes) adjacent to copiers.

How do you prevent a breach when holding conversations vulnerable to eavesdropping outsiders with scanning equipment?

use phones with built-in encryption technology

how to prevent a breach when faxing confidential information to unauthorized persons?

Before transmission, verify the fax number and that the recipient is authorized to receive confidential information.

how to prevent a breach when sending confidential messages that can be overheard on the pager?

restrict use of voice pagers to nonconfidential messages.

what 5 things processes does documentation utilize?

nursing process, patient record, standards, principles, and Code of Ethics & Scope and Standards of Practice

what does ‘PHI’ stand for?

protected health information

what does HIPAA stand for?

Health Insurance Portability and Accountability Act

true or false: only some social media breaches confidentiality

false (all social media)

what does HIPAA look like for student documentation?

Pt initials only, no room numbers or other identifiers, no copying of parts of chart, review only assigned patient, close computer screen when leaving terminal

what are the 4 formats for nursing documentation?

nursing care plans, critical/collaborative pathways, patient care summary, and flow sheets/graphic records

what are the 6 parts of process notes?

Narrative charting (what you saw)

SOAP (subjective, objective, assessment, plan)

PIE (probleem intervention, evaluation)

Focus Charting/ DAR (data, action, response)

Charting by exception (only charting the problems)

At what point in your shift should you document?

in real time (don’t wait until the end of your shift or information can be forgotten and less accurate)

what does “OOB” stand for

out of bed

what does “CVA” stand for?

stroke

what does “CBC” stand for?

complete blood count

what does “NKA” stand for?

no known allergies

what does “BM” stand for?

bowel movement

what does “SOB” stand for?

shortness of breath

what does “NPO” stand for?

nothing by mouth