Information Management & Record of Care

Question 1

How do you protect the
confidentiality of protected
health information (PHI)?

Answer 1

• Log off computer terminals and remove CACs when not in use and at the end of shift.
• Do not discuss patients in public areas.
• Provide visual and auditory privacy when speaking with patients and families.
• Store written patient information in a way that prevents viewing by the public.
• Dispose of confidential paper documents in appropriate bins.

Question 2

Does your hospital have a standard list of prohibited abbreviations?

Answer 2

Yes. A list of prohibited abbreviations is posted in all medication and vaccine storage areas and disseminated to all staff.

Question 3

What is staff expected to do if an unauthorized abbreviation is used in a medical record?

Answer 3

• If you find it abbreviation in the medical record by another member of the patient care team and you do not know what it is, STOP and do not GUESS.
• Get clarification by calling the individual who root the note work order
• Enter a note in the medical record with the correct information before patient care proceeds. Abbreviations can harm patients.

Question 4

What would you do if the EMR went down?

Answer 4

Paper Downtime forms are available in all patient care areas. Scheduled down times are announced and advanced to avoid disruption to care processes.