Management of Care Flashcards
Nursing Process
Assessing
Diagnosing
Planning
Implementing
Evaluating
HIPAA
health insurance portability and accountability Act
Law protecting the right to privacy for clients. It regulates how a clients personal, health information (example: diagnosis, test results) care used and disclosed
HIPAA Key points
Only share client info with other team members directly involved with care
Need to know basis only
No over sharing detailed information with non essential personnel (transporters, secretaries)
Never discuss client info in the hallway, elevator, public area, outside the hospital = secure private area only at work (nurses station, private room)
Do not access charts or information that is not needed directly for work
Computer charting
No password sharing - Not even with supervisor (charge nurse, director)
Log off when stepping away and log off your coworkers if they do leave the computer in the hall unattended
No taking info home
Dispose of report sheets in a secure shredder
Old medical record are kept in a locked file cabinet in the department
Information releases
Yes - clients have a right too receive a copy of the health records
No sharing information with a family or friend without clients permission
Report any breech of confidentiality
violation examples: taking about a clients condition in a hallway, elevator, cafeteria etc.
Taking home a clients report sheet (medical information) must be shredded at the end of shift
Sharing info with a clients roommate (ex. your roommate is going for a gallbladder test)
Sharing info with a clients spouse to legal guardian without permission
Charge nurse from another unit ask about the clients condition stating “the client is my neighbour and I want to check on her”…
Im sorry I cannot tell you
The nurse looks up the chart of a cousin who is not under the care of the nurse. What is the managers next action?
Contact human resource department
A nurse has shared his computer username and password with a student, possible consequences?
The nurse can be prosecuted
Husband requesting lab results for his wife. How should the nurse respond
Let me check if you have permission
19 year old female asks for prescription for oral contraception. She is under her parents insurance but doe not want her parents to know. According to HIPPA, which of the following should the provider tell the patient?
The clients parents may not view the medical record but may learn about it from their insurance billing receipts
Which off the following violates the health information privacy law?
Telling the clients transportation tech that the client has stage 4 pancreatic cancer for 3 weeks and needs to be handled gently
The new grad nurse accessing updated medical records of a client that they took care of last week but not currently assigned
Explaining the results of a clients lab reports to aa sit secretory who is organizing medical records
HIPAA Exception
Information must be shared if the client is threatening to harm themselves or other
If the client is being abused, nurses are the mandatory reporters
the nurse would be justified in breaking confidentiality if…
an older adult client discloses their caregiver hits them
Autonomy
Always in control
The clients right to make their down healthcare decisions
Respecting a clients right to refuse a treatment
Advocacy
To protect the clients rights, health and safety
Reporting critical changes in the clients condition
Beneficence
Benefit
Doing and promoting good
Calling the family of a client to tell them “critically ill and we are caring for their needs”
Fidelity
“faithful”
To stay loyal and follow through
Ex. follow through with your responsibilities
Client reports 8/10 pain. The nurse states she will return with pain meds and follows through with the act
Fidelity
Justicie
To treat fairly and equally
Provide care equally regardless of race, gender, religion, culture
Ensuring that time and resources are distributed equitably to clients
Nonmaleficene “no Mal-intent”
Avoid causing harm
Double checking drug dosage
Veracity
Very honest
Tell the truth
Med error with no adverse affects but till reporting it
Negligence
The failure to provide adequate care
Practice that its below the standard of care
nurse did not wash their hands prior to inserting a Foley catheter
Nurse identifies the absence of peripheral pulse in a clients casted extremity in the early morning. The nurse reports it to the HCP in the early afternoon
If informed consent is withheld from a client
Health carer providers could be found guilty fo negligence
Malpractice
illegal improper or negligent actions by a licensed professional
Rn failed to check the doses on a medical viral which harmed the client
Abandonment
Desertion of a client by anyone who has assumed the responsibility of care
Assault
The threat of harm
Any threat made toward a client
I will restrain you to the bed if you keep getting up
Threatening to place a nasogastric tube in a client who is refusing to eat
Battery
The act of arm
Physical act that causes harm or unconsenting contact that causes harm
Example: performing a procedure without consent
Giving medication that the client refuses
Assault and Battery Example: chemical restraining a patient who is competent and able to make decisions
False imprisonment
Using physical restraints, reclusion or a chemical restrain to keep someone against their will
Example using restraints on a competent client to prevent them leaving the health care facility
