Confidentiality - Documenting and Reporting

Question 1

Nurses are legally and ethically obligated to keep information about patients ___.

Answer 1

confidential

Question 2

Only members of the health care team who are d___ involved in a patient’s care have legitimate access to the medical record. Thus, the nurse discusses a patient’s diagnosis, treatment, assessment, and/or any personal conversations only with members of the health care team who are involved in a patient’s care.

Answer 2

d-irectly

Question 3

A breach of confidentiality is often a c___ rather than a deliberate act. Students need to make sure that patient-identifiable information (e.g., files, stickers, information in notebooks, worksheets) is not taken home and that it is disposed of correctly in a secure bin for shredding.

Answer 3

c-areless

Question 4

Examples of breaches of ___ are accessing information not related to your duties, discussing patient information in an inappropriate area, such as in an elevator or on public transport, revealing to a caller confidential patient or co-worker details, emailing patient information through a public network such as the Internet, and leaving confidential material in a public area.

Answer 4

confidentiality

Question 5

Even after you are no longer on placement at an agency, you are obligated to maintain the ___ of patients and co-workers at that agency.

Answer 5

confidentiality

Question 6

Includes individually identifiable health information such as demographic data; facts that relate to an individual’s past, present, or future physical or mental health condition; provision of care; and payment for the provision of care that identifies the individual.

Answer 6

Personal health information (PHI)

Question 7

True or false: ensuring appropriate access to and confidentiality of personal health information (PHI) is the responsibility of all people working in health care.

Answer 7

True

Question 8

Federal legislation that protects personal information, including health information.

Answer 8

Personal Information Protection and Electronic Documents Act (PIPEDA)

Question 9

Delineates how private-sector organizations may collect, use, or disclose personal information in the course of commercial activities. Individuals have the right to access and request correction of any personal information collected about them as well.

Answer 9

Personal Information Protection and Electronic Documents Act (PIPEDA)

Question 10

Applies to all organizations engaged in commercial activities unless the federal government exempts an organization or activity in a province with similar legislation.

Answer 10

The Personal Information Protection and Electronic Documents Act (PIPEDA)

Question 11

A combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information.

Answer 11

Firewall

Question 12

Includes placing computers or file servers in restricted areas or using privacy filters for computer screens visible to visitors or others without access. This form of security has limited benefit, especially if an organization uses mobile wireless devices such as notebooks, tablets, personal computers (PCs), and smart phones. These devices are easily misplaced or lost, falling into the wrong hands. Some organizations use motion detectors or alarms with these devices to help prevent theft.

Answer 12

Physical security measures

Question 13

Safety mechanism that logs a user off a computer system after a specified period of inactivity.

Answer 13

Automatic sign-off

Question 14

A collection of alphanumeric characters that a user types into a computer before accessing a program after the entry and acceptance of an access code or user name. This should not be shared with anyone or anything.

Answer 14

Passowrd

Question 15

To protect patient privacy, health care agencies ___ who accesses patient records and when they access them.

Answer 15

track

Question 16

Destroy (e.g., s___) anything that is printed when the information is no longer needed.

Answer 16

s-hread

Question 17

When writing patient data onto forms or including it in papers written for nursing courses, you need to ___-identify all patient data.

Answer 17

de

Question 18

True or false: historically the primary sources for inadvertent, unauthorized disclosure of PHI occurred when information was printed from a patient record and/or faxed to other health care providers.

Answer 18

True

Question 19

Nurses need to destroy all papers containing PHI (e.g., social insurance number, date of birth or age, patient’s name or address) ___ after using or faxing them.

Answer 19

immediately

Question 20

Some nurses work in settings where they are responsible for erasing files from a computer hard drive that contain calendars, surgery or diagnostic procedure schedules, or other daily records that contain PHI. It is important to know and follow the disposal ___ for records in the institution where you work.

Answer 20

policies

Question 21

Health care facilities and departments have policies for the use of fax machines, which specify the ___ of information that can be faxed, allowable recipients of the information, where information is sent, and the process used to verify that information was sent to and received by the appropriate person(s).

Answer 21

types

Question 22

Nurses should fax only the amount of information that is requested or required for immediate clinical needs. The following are some steps to take to enhance fax security:

• Confirm that fax numbers are ___ before sending to be sure that you direct information properly
• Use a ___ sheet to eliminate the need for the recipient to read the information to determine who gets it. This is especially important if a fax machine serves a number of different users.
• Authenticate at both ends before data transmission to verify that source and destination are correct. Use the cover sheet to list intended recipient(s), the sender, and the phone and fax numbers. Verify the fax number on the transmittal confirmation sheet.
• Use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information.
• Use the en___ feature on the fax machine. Encoding transmissions makes it impossible to read confidential information without the encryption key.
• Place fax machines in a secure area and limit machine access to designated individuals.
• Log fax transmissions. This feature is often available electronically on the machine.

Answer 22

correct

cover

en-cryption