Study Guide for Fundamentals of Nursing The Art and Science of Nursing Care

CHAPTER 17 DOCUMENTING, REPORTING, CONFERRING, AND USING INFORMATICS 91

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4.Which of the following are incidental

disclosures of patient health information that

are permitted by HIPAA? (Select all that apply.)

a.The use of sign-in sheets that contain

information about the reason for the

patient visit

b.The possibility of a confidential

conversation being overheard, provided

that the surroundings are appropriate and

voices are kept down

c.The unlimited use of white boards

d.X-ray light boards that can be seen by

passersby, provided that patient x-rays are

not left unattended on them

e.Calling out names in the waiting room,

provided that the reason for the patient

visit is not mentioned

f.Leaving detailed appointment reminder

messages on a patient’s voice mail

5.Which of the following statements accurately

describe a method of documentation? (Select

all that apply.)

a.In a source-oriented record, each healthcare

group keeps data on its own separate form.

b.In a problem-oriented record, the entire

healthcare team works together in identify-

ing a master list of patient problems and

contributes collaboratively to the plan of

care.

c.In the PIE charting system, a separate plan

of care is developed.

d.In focus charting, a problem list of nursing

or medical diagnoses is used that

incorporates many aspects of a patient and

patient care.

e.In charting by exception, only significant

findings or “exceptions” to these standards

are documented.

f.In the case management model, a collabo-

rative pathway is part of a computerized

documentation system that integrates the

collaborative pathway and documentation

flow sheets designed to match each day’s

expected outcomes.

6.Which of the following are basic components

of the Resident Assessment Instrument (RAI)?

(Select all that apply.)

a.Patient record

b.Maximum data set

c.Triggers

d.Resident assessment protocols

e.Utilization guidelines

f.Resident nurse practice acts

Hot Spot Question

1.Place an X on the clock below that shows the

military time of 2230.

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