N320 Final Flashcards
HIPAA
Health Insurance Portability and Accountability Act
Covered entities: healthcare providers, health plans, healthcare clearinghouses, business associates
Health care clearinghouses
Receive individually identifiable health information only when they are providing these processing services to a health plan or healthcare provider as a business associate
Business associates
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)
Who oversees HIPAA
USDHHS (US department of health and human services office of civil rights)
Communication; diagnostic and therapeutic orders; care planning; quality process and performance improvement; research & decision analysis; education; credentialing, regulation, legislation; reimbursement; legal and historical documentation
Purpose of patient records
Consistent; complete; concise; accurate; factual; organized and timely; legally prudent; confidential
Elements of effective documentation
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
9 types of documentation errors
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
Potential breaches in patient confidentiality
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
Patient rights
Used in emergency situations only
Record orders with date and time
Read back order
Name of physician followed by nurses name and initials
Verbal orders
Facilitate quality, evidence-based patient care
Serve as a financial and legal record
Help in clinical research
Support decision analysis
Purpose of documentation
Patients fill in information from their own records and the information is stored on patients’ computers or the internet
Standalone personal health records
Records linked to a specific health care organization’s electronic health record (EHR) system or to a health plan’s information system
Tethered/connected personal health records
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)
SOAP (problem-oriented medical records)
Problem, Intervention, Evaluation Charting
PIE charting
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)
Focus charting
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
Charting by exception (CBE)
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
Change of shift/hand-off report
Any group of people who live together and depends on one another for physical, emotional, and financial support
Family
Traditional family, two parents and their children
Nuclear family
Includes aunts, uncles, and grandparents
Extended family
Two parents and their unrelated children from previous relationships
Blended family
May be separated, divorced, widowed, or never married
Single-parent family
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
Family functions
Standard or rule of conduct established and enforced by the government; designed to protect the rights of the public
Law
Government is directly involved; regulates relationships between individuals and the government
Public law
Civil law; regulates relationships among people
Private law
Concerns state and federal criminal statuses; defines criminal actions (e.g. murder, theft, etc.)
Criminal law
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)
4 Sources of Law
Process of bringing and trying a lawsuit
Litigation
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
Plaintiff
Person being accused of a crime; presumed innocent until proven guilty of a crime or tort
Defendant
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
Nurse Practice Acts
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
Standards
Ways in which professional competence is assured and maintained. Includes:
Accreditation
Licensure
Certification
Credentialing
The process by which an educational program is evaluated and recognized as having met certain standards
Accreditation
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
Licensure
The process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area
Certification
A violation punishable by the state; acts against one or more victims or the public
Crime
A less serious crime, commonly punishable with a fine, imprisonment for less than 1 year, or both, or with parole
Misdemeanor
A crime such as rape or murder that is punishable by imprisonment in a state or federal penitentiary for more than 1 year
Felony
Either intentional or unintentional acts of wrongdoing
Torts
Intentional tort; a threat or an attempt to make bodily contact with another person without that person’s consent
Assault
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
Battery
An intentional tort in which one party makes derogatory remarks about another that diminish the other party’s reputation
Slander = spoken
Libel = written
Defamation of character
Intentional tort in which citizens’ right to privacy, right to be left alone, and right to have information kept private are violated
Invasion of Privacy
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
False Imprisonment
Willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property
Fraud
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)
Negligence
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
Malpractice
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)
Liability
Self-determination; being independent and self-governing
Autonomy
The principle of doing good
Beneficence
The ability to behave in an ethical way; to do the ethically right thing because it is the right thing to do
Moral agency
A situation that arises when attempted adherence to basic ethical principles results in two conflicting courses of action
Ethical dilemma
Type of ethical approach that aims to critique existing patterns of oppression and domination in society, especially as these affect women and the poor
Feminist ethics
Fidelity
Keeping promises and commitments made to others
Process that distributes benefits, risks, and costs fairly
Justice
Developed capacity to respond well to morally distressing experiences and to emerge strong
Moral resilience
Principle of avoiding evil; DO NO HARM
Non-maleficence
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
Nursing Ethics
Feelings of frustration, anger, anxiety w/ institutional obstacles/conflict with others’ values or decisions
Initial distress
Distress felt when a person didn’t act upon initial distress
Reactive distress
That which is carried with us after we have compromised ourselves/beliefs/morals/ethics
Moral residue
