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Nursing > N320 Final > Flashcards

N320 Final Flashcards

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1
Q

HIPAA

A

Health Insurance Portability and Accountability Act
Covered entities: healthcare providers, health plans, healthcare clearinghouses, business associates

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2
Q

Health care clearinghouses

A

Receive individually identifiable health information only when they are providing these processing services to a health plan or healthcare provider as a business associate

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3
Q

Business associates

A

A person or organization (other than a member of a covered entity’s workforce) using or disclosing individually identifiable health information to perform or provide functions, activities, or services for a covered entity (claims processing data analysis, utilization review, billing)

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4
Q

Who oversees HIPAA

A

USDHHS (US department of health and human services office of civil rights)

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5
Q

Communication; diagnostic and therapeutic orders; care planning; quality process and performance improvement; research & decision analysis; education; credentialing, regulation, legislation; reimbursement; legal and historical documentation

A

Purpose of patient records

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6
Q

Consistent; complete; concise; accurate; factual; organized and timely; legally prudent; confidential

A

Elements of effective documentation

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7
Q

Sloppy or illegible handwriting
Failure to date/time/sign a medical entry
Lack of documentation or omitted medications and/or treatments
Incomplete or missing documentation
Adding entries later on (should be done when the task is completed)
Documenting subjective data
Not questioning incomprehensible orders
Using the wrong abbreviations
Entering information into the wrong chart

A

9 types of documentation errors

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8
Q

Displaying information on a public screen
Sending confidential email messages via public networks
Sharing printers among units with differing functions
Discarding copies of patient information in trash cans
Holding conversations that can be overheard
Faxing confidential forms to unauthorized persons

A

Potential breaches in patient confidentiality

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9
Q

See a copy of their health records
Update their health records
Get a list of disclosures
Request a restriction on certain use of disclosures
Choose how to receive health information

A

Patient rights

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10
Q

Used in emergency situations only
Record orders with date and time
Read back order
Name of physician followed by nurses name and initials

A

Verbal orders

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11
Q

Facilitate quality, evidence-based patient care
Serve as a financial and legal record
Help in clinical research
Support decision analysis

A

Purpose of documentation

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12
Q

Patients fill in information from their own records and the information is stored on patients’ computers or the internet

A

Standalone personal health records

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13
Q

Records linked to a specific health care organization’s electronic health record (EHR) system or to a health plan’s information system

A

Tethered/connected personal health records

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14
Q

Subjective (statement about relevant patient behavior or status)
Objective (measurable, quantifiable, and observable data)
Assessment (interpret the meaning of S and O)
Plan (anticipated frequency and duration, course of treatment for next session, recommendations, and any changes)

A

SOAP (problem-oriented medical records)

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15
Q

Problem, Intervention, Evaluation Charting

A

PIE charting

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16
Q

Brings the focus of care back to the patient and the patient’s concerns; focus may be a patient strength, problem, or need; uses DAR note format
D(ata)
A(ction)
R(esponse)

A

Focus charting

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17
Q

Only significant findings (exceptions) are documented in a narrative format
Presumes that unless documented otherwise, all standardized protocols have been met and no further documentation is needed

A

Charting by exception (CBE)

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18
Q

Includes:
Basic identifying patient information
Current appraisal of each patient’s health status
Current orders (especially any newly changed orders)
Abnormal occurrences during the shift
Any unfulfilled orders that need to be continued onto the next shift
Patient/family question, concerns, needs
Report on transfers/discharge

A

Change of shift/hand-off report

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19
Q

Any group of people who live together and depends on one another for physical, emotional, and financial support

A

Family

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20
Q

Traditional family, two parents and their children

A

Nuclear family

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21
Q

Includes aunts, uncles, and grandparents

A

Extended family

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22
Q

Two parents and their unrelated children from previous relationships

A

Blended family

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23
Q

May be separated, divorced, widowed, or never married

A

Single-parent family

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24
Q

Physical: provides a safe, comfortable environment necessary for growth, development, and rest/recuperation
Economically: provides financial aid to members and also helps meet society’s needs
Reproductive: to have and raise children
Affective/coping: provide emotional comfort to family members and help members establish their identity and maintain it in times of stress
Socialization: family teaches, transmits beliefs, values, attitudes, and coping mechanisms; provides feedback and guides problem-solving

A

Family functions

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25
Q

Standard or rule of conduct established and enforced by the government; designed to protect the rights of the public

A

Law

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26
Q

Government is directly involved; regulates relationships between individuals and the government

A

Public law

27
Q

Civil law; regulates relationships among people

A

Private law

28
Q

Concerns state and federal criminal statuses; defines criminal actions (e.g. murder, theft, etc.)

A

Criminal law

29
Q

Constitutions (serves as guides to legislative bodies)
Statutory law (enacted by a legislative body)
Administrative law (empowered by executive officers)
Common law (judiciary system reconciles controversies)

A

4 Sources of Law

30
Q

Process of bringing and trying a lawsuit

A

Litigation

31
Q

Person pr government bringing the suit; claims to have incurred losses as a result of an action by the defendant; ex: patient accusing nurse of malpractice

A

Plaintiff

32
Q

Person being accused of a crime; presumed innocent until proven guilty of a crime or tort

A

Defendant

33
Q

Protects the public by broadly defining the legal scope of nursing practice; lists violations that can result in disciplinary action against a nurse and also prevent untrained or unlicensed people from practicing nursing

A

Nurse Practice Acts

34
Q

Include requirements for the certification of individual nurses in general and in specialty areas of practice; requirements for accreditation of education programs and service organizations

A

Standards

35
Q

Ways in which professional competence is assured and maintained. Includes:
Accreditation
Licensure
Certification

A

Credentialing

36
Q

The process by which an educational program is evaluated and recognized as having met certain standards

A

Accreditation

37
Q

The process by which a state determines that a candidate meets certain minimum requirements to practice in the profession and grants a license to do so

A

Licensure

38
Q

The process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area

A

Certification

39
Q

A violation punishable by the state; acts against one or more victims or the public

A

Crime

40
Q

A less serious crime, commonly punishable with a fine, imprisonment for less than 1 year, or both, or with parole

A

Misdemeanor

41
Q

A crime such as rape or murder that is punishable by imprisonment in a state or federal penitentiary for more than 1 year

A

Felony

42
Q

Either intentional or unintentional acts of wrongdoing

A

Torts

43
Q

Intentional tort; a threat or an attempt to make bodily contact with another person without that person’s consent

A

Assault

44
Q

Intentional tort; an assault that is carried out and includes willful, angry, and violent or negligent touching of another person’s body or clothes or anything attached to or held by that other person

A

Battery

45
Q

An intentional tort in which one party makes derogatory remarks about another that diminish the other party’s reputation
Slander = spoken
Libel = written

A

Defamation of character

46
Q

Intentional tort in which citizens’ right to privacy, right to be left alone, and right to have information kept private are violated

A

Invasion of Privacy

47
Q

Intentional tort in which unjustified retention or prevention of the movement of another person without proper consent; can also be the indiscriminate and thoughtless use of restraints

A

False Imprisonment

48
Q

Willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property

A

Fraud

49
Q

Performing an act that a reasonably prudent person under similar circumstances would not do or, conversely, failing to perform an act that a reasonably prudent person under similar circumstances would do; an act of omission or commission (unintentional tort)

A

Negligence

50
Q

Used to describe negligence by professional personnel
Failure to follow standards of care
Failure to use equipment in a responsible manner
Failure to assess and monitor
Failure to communicate
Failure to document
Failure to act as a patient advocate or to follow the chain of command

A

Malpractice

51
Q

Involves four elements that must be established to prove that malpractice or negligence has occurred
Duty (obligation to use due care)
Breach of duty (failure to meet the standard of care)
Causation (shows that the failure to meet the standard of care actually caused the injury)
Damages (actual harm or injury resulting to the patient)

A

Liability

52
Q

Self-determination; being independent and self-governing

A

Autonomy

53
Q

The principle of doing good

A

Beneficence

54
Q

The ability to behave in an ethical way; to do the ethically right thing because it is the right thing to do

A

Moral agency

55
Q

A situation that arises when attempted adherence to basic ethical principles results in two conflicting courses of action

A

Ethical dilemma

56
Q

Type of ethical approach that aims to critique existing patterns of oppression and domination in society, especially as these affect women and the poor

A

Feminist ethics

57
Q

Fidelity

A

Keeping promises and commitments made to others

58
Q

Process that distributes benefits, risks, and costs fairly

A

Justice

59
Q

Developed capacity to respond well to morally distressing experiences and to emerge strong

A

Moral resilience

60
Q

Principle of avoiding evil; DO NO HARM

A

Non-maleficence

61
Q

A subset of bioethics; formal study of ethical issues that arise in the practice of nursing and of the analysis used by nurses to make ethical judgments

A

Nursing Ethics

62
Q

Feelings of frustration, anger, anxiety w/ institutional obstacles/conflict with others’ values or decisions

A

Initial distress

63
Q

Distress felt when a person didn’t act upon initial distress

A

Reactive distress

64
Q

That which is carried with us after we have compromised ourselves/beliefs/morals/ethics

A

Moral residue

Nursing (8 decks)

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