Question 1

Nursing home policy states that a registered nurse must cosign all charts that licensed practical nurses complete. What is the effect of this policy on the registered nurse?
A) It places the RN in the position of endorsing and authenticating the entries made in the charts cosigned.
B) It gives legal proof that the RN was in the facility.
C) It has no legal effect on the RN.
D) It makes the RN personally liable for any subsequent harm that befalls the patient.

Accepted Answer

Rationale 1: Cosigning is a practice that is becoming less frequent. It does place the nurse potentially liable for care, observations, or omissions as charted.
Rationale 2: The RN may have cosigned at a date other than that of the event, so it does not give absolute proof that the RN was in the facility.
Rationale 3: There are legal implications for endorsing or authenticating entries by cosigning.
Rationale 4: The person delivering the care is also liable for any harm that may occur due to malpractice. Liability does not lie exclusively with the person who cosigned.

Question 2

A newly licensed nurse complains to the preceptor about the amount of time spent documenting in the medical record. What is the preceptor's best response?
A) "The most important reason we document is to help us communicate the patient's condition to the rest of the health care team."
B) "Since you just took a course in nursing research, you should realize the value of accurate documentation as a source of research data."
C) "We have to document so that charges are clear to third-party payers."
D) "The medical record protects us if a lawsuit is filed."

Accepted Answer

Rationale 1: The primary reason for documentation is to communicate the patient's condition to others on the health care team. The preceptor should remind the newly licensed nurse of this fact.
Rationale 2: Information from the medical record can be used for research with the patient's permission, but this is not the primary reason it is important.
Rationale 3: It is true that accurate documentation supports third-party reimbursement, but this is not the most important use of this information.
Rationale 4: The medical record may or may not offer information that would protect the nurse in case of a lawsuit. This is not the primary reason for documentation.

Question 3

The nurse working in a physician's office recorded assessment data in the wrong patient's medical record about 1 hour ago. How should the nurse correct this error?
A) Black out the error with a marker and enter the new information.
B) Indicate the date and time the correction was made.
C) Indicate the reason the correction is being made by writing "wrong patient chart" along with the new information.
D) Enclose the corrected information in brackets to set it off from the original post.
E) Either initial or sign the correction.

Accepted Answer

Rationale 1: The information written in error should not be obliterated or blacked out.
Rationale 2: The nurse should indicate the date and the time the correction was made in order to show when the new notation was made.
Rationale 3: There should be some indication of why the correction is being made. "Wrong patient chart" is adequate explanation.
Rationale 4: There is no reason to bracket the new information.
Rationale 5: Depending upon the extent of the correction, the nurse should either initial or sign the corrected area. It is important to make it very clear who made the new notation.

Question 4

A patient incident occurred on the nursing unit. What should the nurse caring for the patient do in regard to the incident report?
A) Carefully document the completion of an incident report in the nurse's notes.
B) Write a recommendation for future prevention of such incidents in the report.
C) Include only the facts and the nurse's observations in the incident report.
D) Assist the nursing supervisor who will write the report.
E) Include documentation in the medical record about the event that mandated completion of an incident report.

Accepted Answer

Rationale 1: The completion of an incident report should never be referenced or documented in the nurse's notes, which are a part of the patient record. This report is for institutional use only.
Rationale 2: Recommendations for prevention are not part of the incident report.
Rationale 3: The nurse should include what was actually observed in this report.
Rationale 4: The person discovering or directly involved in the incident must complete the report. This could be any staff member, not just the nursing supervisor.
Rationale 5: The facts of what happened to the patient and the patient's response must be documented in the medical record.

Question 5

The nurse discussing the Health Insurance Portability and Accountability Act (HIPAA) says, "I am aware that this act changed the way we handle confidential information." What other provisions of this act should the nurse consider?
A) An anti-fraud and anti-abuse program
B) Establishment of state governments as health care regulators
C) A law preventing portability of health care coverage
D) Tax incentives for preventive care
E) Streamlining of transfer of patient information between insurers and providers

Accepted Answer

Rationale 1: An anti-fraud and anti-abuse program is part of HIPAA.
Rationale 2: The act established the federal government as a national health care regulator.
Rationale 3: This act provides for the portability of health care coverage.
Rationale 4: There are no tax incentives for preventive care included in this act.
Rationale 5: HIPAA was designed to help streamline transfer of patient information between insurers and providers. As part of this streamlining effort, changes to confidentiality also occurred.

Question 6

The parents of a 17-year-old who is receiving state-funded substance abuse treatment have asked the provider for information about their child. What is the correct action by the health care provider?
A) Refuse the request pursuant to the provision of the common-law duty to disclose.
B) Refuse the request as it is likely to interfere with the treatment plan.
C) Release the information immediately as parents always can receive information on minor children.
D) Release information only if the patient has signed consent to do so.

Accepted Answer

Rationale 1: The common-law duty to disclose recognizes the duty to disclose medical information in limited circumstances related to public safety.
Rationale 2: Interference with the treatment plan is not the primary concern.
Rationale 3: It is not true that parents can always receive information on minor children.
Rationale 4: A minor must always sign consent for information about substance abuse to be released, even to a parent.

Question 7

The nursing student began a case study paper by writing, "J.P., a 65-year-old Asian male, was admitted to the intensive care unit at Southwest Hospital." What is the significance of this statement?
A) It is incomplete, as the date and time of admission should be included.
B) It is a good description of the patient to begin the paper.
C) It violates Health Insurance Portability and Accountability Act regulations.
D) It is incomplete, as the patient's physician's name should be included.

Accepted Answer

Rationale 1: Inclusion of additional information such as date and time of admission only makes it easier to identify the patient, which is a HIPAA violation.
Rationale 2: Since information about age, race, and gender is important to the faculty grading the case study, that information should be included.
Rationale 3: The inclusion of the patient's initials, age, race, and place of admittance potentially makes it possible to identify the patient, which violates HIPAA.
Rationale 4: The patient's physician's name should not be included as it makes it easier for others to identify the patient.

Question 8

The patient brings suit against a health care provider. In which ways would the nurse expect this action will affect the confidentiality of the patient's medical record?
A) The confidentiality of the record will remain intact.
B) The patient's attorney will have access to the information in the record.
C) The record loses confidentiality and is discoverable by any interested party.
D) The record will be released to the defendant's attorney.
E) Only the judge will have full access to the medical record.

Accepted Answer

Rationale 1: As being the primary source to describe the course of the patient's evaluation, treatment, and change in condition, the medical record is a discoverable record.
Rationale 2: The patient's attorney must have access to this information in order to pursue the lawsuit.
Rationale 3: Information in the medical record is not discoverable to anyone who is not involved in the suit.
Rationale 4: The defendant's attorney will have access to the medical record.
Rationale 5: Others other than the judge must have access to the medical record to establish and defend the suit.

Question 9

As part of conversion to a new electronic medical record format, a hospital is also instituting charting by exception. The nurse manager would caution staff nurses that charting by exception has which major drawback?
A) It may not provide enough information to support trending of the patient's condition.
B) It does not allow for use of uniform standards.
C) It is not admissible in court because there is not enough background in the documentation.
D) This method takes much more time than narrative charting.

Accepted Answer

Rationale 1: The major problem with charting by exception is that it is often difficult to see the changes or trends that may indicate worsening of the patient's condition.
Rationale 2: In order for charting by exception to be meaningful, uniform standards must first be established.
Rationale 3: Charting by exception is admissible in court.
Rationale 4: Charting by exception was designed to reduce charting time.

Question 10

A patient requests that records of her hospitalization for treatment of an infection following an abortion be destroyed as soon as she is discharged. What is the likely outcome of this request?
A) The record will be sealed.
B) The record will be destroyed.
C) The request will be denied.
D) The record will be given to the patient's attorney.

Accepted Answer

Rationale 1: Even though the patient has requested that the record be destroyed, medical records departments are generally unwilling to do so. In most cases, the record will be sealed rather than destroyed.
Rationale 2: Destroying the medical record is a permanent action that is generally done only after a specified amount of time, often several years. It is unlikely that the medical records department will honor this request.
Rationale 3: Simply denying the patient's request does not fulfill the patient's need for privacy of information.
Rationale 4: The hospital will not turn the only copy of this record over to the patient's attorney. If a lawsuit were to be filed, the hospital would have no record of the hospitalization.

Question 11

The patient demands to see the actual medical record of a hospitalization that occurred 1 year ago. How should the hospital handle this request?
A) Deny the demand; the patient has no legal right to this record.
B) Have the patient come to the hospital to review the original record.
C) Send the patient a copy of the medical record by registered mail.
D) Do not comply with this demand unless the patient provides a subpoena for the record.

Accepted Answer

Rationale 1: The patient does have a legal right to view the record.
Rationale 2: In this case, the hospital should have the patient come to the hospital to review the original record. The patient should be monitored while reviewing this record.
Rationale 3: Making a copy of the record for the patient does not fulfill the patient's demand or the patient's right to see the original.
Rationale 4: Since the patient has a right to see the original record, there is no need for a subpoena.

Question 12

A nurse strongly believes that all newborns should be screened for HIV at birth. Which ethical principle would the nurse cite to support this argument?
A) Informed consent
B) Confidentiality
C) Beneficence
D) Autonomy

Accepted Answer

Rationale 1: Informed consent might be transgressed through mandatory testing.
Rationale 2: Confidentiality might be transgressed by mandatory testing.
Rationale 3: The principle of beneficence (greatest good for greatest number) supports HIV screening of newborns.
Rationale 4: Autonomy might be transgressed through mandatory testing.

Question 13

A nurse is preparing information to be distributed at a national conference on AIDS. What should be included regarding mandatory disclosure of AIDS status?
A) Every state requires that all sexual contacts of a person diagnosed with AIDS be contacted and treated.
B) AIDS status must be disclosed to any health care provider who has cared for the patient within the last 18 months and to any future health care provider.
C) In general AIDS status is considered confidential.
D) All AIDS cases must be reported to the Centers for Disease Control and Prevention or to the state health department.
E) All babies born in the United States are tested for presence of HIV at birth.

Accepted Answer

Rationale 1: Not all states require or permit this tracking and content.
Rationale 2: There is no regulation mandating disclosure of AIDS status to health care providers.
Rationale 3: In general AIDS status is considered confidential. There are very limited situations in which this status can be disclosed.
Rationale 4: All 50 states require reporting of AIDS cases to the Centers for Disease Control and Prevention or to the state health department for epidemiological purposes.
Rationale 5: There is no universal standard by which all babies are tested for HIV at birth.

Question 14

The nurse manager is aware that several patients will be admitted to the unit today. Today's staff includes three registered nurses, two licensed practical nurses, and three unlicensed nursing assistants. Who should the manager expect to assess and document the admitted patient's nursing needs?
A) The nursing assistant
B) The admitting physician
C) A registered nurse
D) A licensed practical or vocational nurse

Accepted Answer

Rationale 1: The nursing assistant may collect data such as vital signs, but cannot use the data to plan care.
Rationale 2: The physician plans medical care, not nursing care.
Rationale 3: Documentation of admission assessment and nursing needs is the role of the registered nurse.
Rationale 4: The LPN or LVN can collect data, but does not use the data to plan care.

Question 15

Which statement, made by a staff nurse, would the nurse manager evaluate as evidence of good understanding of the importance of the electronic medical record?
A) "Since nurses are the only ones using this system, I won't have to wait to document anymore."
B) "I'm glad that it will take less time for us to document."
C) "I hope we don't have to keep changing passwords."
D) "They say that our patient care will improve while we are using this system."

Accepted Answer

Rationale 1: Access to the record is not limited to nursing; all disciplines use the system.
Rationale 2: It does not take less time to document fully using this system.
Rationale 3: Passwords are changed frequently for security purposes.
Rationale 4: Electronic records allow immediate access to patient care information; therefore, patient care is improved.

Quiz 9: Documentation and Confidentiality

Nursing home policy states that a registered nurse must cosign all charts that licensed practical nurses complete. What is the effect of this policy on the registered nurse?

A newly licensed nurse complains to the preceptor about the amount of time spent documenting in the medical record. What is the preceptor's best response?

The nurse working in a physician's office recorded assessment data in the wrong patient's medical record about 1 hour ago. How should the nurse correct this error?

A patient incident occurred on the nursing unit. What should the nurse caring for the patient do in regard to the incident report?

The nurse discussing the Health Insurance Portability and Accountability Act (HIPAA) says, "I am aware that this act changed the way we handle confidential information." What other provisions of this act should the nurse consider?

The parents of a 17-year-old who is receiving state-funded substance abuse treatment have asked the provider for information about their child. What is the correct action by the health care provider?

The nursing student began a case study paper by writing, "J.P., a 65-year-old Asian male, was admitted to the intensive care unit at Southwest Hospital." What is the significance of this statement?

The patient brings suit against a health care provider. In which ways would the nurse expect this action will affect the confidentiality of the patient's medical record?

As part of conversion to a new electronic medical record format, a hospital is also instituting charting by exception. The nurse manager would caution staff nurses that charting by exception has which major drawback?

A patient requests that records of her hospitalization for treatment of an infection following an abortion be destroyed as soon as she is discharged. What is the likely outcome of this request?

The patient demands to see the actual medical record of a hospitalization that occurred 1 year ago. How should the hospital handle this request?

A nurse strongly believes that all newborns should be screened for HIV at birth. Which ethical principle would the nurse cite to support this argument?

A nurse is preparing information to be distributed at a national conference on AIDS. What should be included regarding mandatory disclosure of AIDS status?

The nurse manager is aware that several patients will be admitted to the unit today. Today's staff includes three registered nurses, two licensed practical nurses, and three unlicensed nursing assistants. Who should the manager expect to assess and document the admitted patient's nursing needs?

Which statement, made by a staff nurse, would the nurse manager evaluate as evidence of good understanding of the importance of the electronic medical record?