Week 4 Lecture Confidentiality, information security Continuity of care Establishing Priorities Flashcards
What does HIPAA stand for
Health insurance portability and accountability act
How does HIPAA protect clients?
For individually identifiable health information
Gives patients rights in respect to that information
Permits disclosure of health information needed for client care
Permits disclosure of health information for insurance reimbursement
Permits disclosure of health information for quality improvement activities
Client must consent in writing to have identifiable for medical information shared outsite of the above
Privacy Rule
falls under HIPAA, protects all oral, written and electronic
→ ´Name, date of birth, SSN, health information (past, present, future), demographic information (address, phone number, email), billing & payment information, information about relatives, household members and employers
How does HIPAA legally limit access to medical records to those on a need to know basis
Direct need to know: Nurse, UAP, Dietitian, student nurse
Indirect need to know: Unit Manager, infection control nurse, health insurance company
What is health information that is to remain confidential?
Client’s chart/medical record
Conversations about client’s care/treatment
Billing information
Information in organizations computer system
How can nurses maintain client confidentiality?
Never discuss with those who do not have a need to know
Protect and secure written records
Log off after every entry
Never share your password
Don’t share information via phone or email unless secrete code is provided
Social media and cell phones STRICTLY PROHIBITED
Adhere to organizations regulations, policies and procedures
Dispose of protected information in confidential bin, shredding
Written permission
required for provider to give information to an employe
When is it acceptable to share information without the clients permission?
Can share to coordinate care with other team members
Medical emergency
Shared for payment, quality assessment, legal issues, auditing, training, evaluating performance or providers
May release information to relative or significant other if client can’t approve due to illness or injury
Describe the confidentiality that comes with photographing clients?
Permission is needed when name, face, or unique feature shown
Permission is not needed is taken as part of a client’s medical record or when it does not show enough information to ID client
Photographs are protected health information
– Same protection for written information apply to photos
Minor privacy
Minors have a right to privacy but most situations legal guardian or parent is authorized to receive and release minors protected health information
Minor privacy: suspision of parental abuse
Is suspicion of parental abuse, neglect or endangerment then parents cannot control minors information
Parents and minor confidentiality - they can agree to what?
Parent can agree to a confidential relationship between provider and minor
Can parent and caregiver discuss minors health information without permission?
Not appropriate to discuss client’s information with caregiver without client’s permission
What are examples of emancipated minors?
Emancipated minor - marriage, pregnancy, armed forces, court order
What should the nurse do if she observes action to neonate?
neonates safety and protection becomes first priority
Deidentified health information
No limits on use of deidentified health information, it isn’t protected by the privacy rule
Includes any health information that doesn’t reveal client’s commonly identifiable information
Ex. case study presented at a conference where fictitious name is used
How can we assess staff member and client understanding of confidentiality requirements?
Observe staff as they perform their roles to assess if they uphold these rights
Assess their knowledge about HIPAA
Take note of conversations in public areas
Assess is computers are being logged off from or sitting open
Does staff secure written medical records
How does staff respond to questions about clients from visitors
Assess clients for knowledge of rights, assess if staff is evaluation client knowledge about confidentiality
How can you intervene appropriately when confidentiality has been breached by staff members
Professional, ethical and legal responsibility of the RN to insure client rights and HIPAA rights are upheld, supported and advocated
If RN witnesses breach of confidentiality – INTERVENE by correcting the situation immediately and don’t allow it to continue. Report chain of command for your organization
Breeches are subject to fines, civil and criminal liability
Continuity of care Timely
smooth unfragmented transition of a client during a change in level of care, transfer to a different facility, or discharge to home
report should include what
change of shift, transfer or report to provider
critical component of continuity of care
how to facilities ensure smooth continuity of care?
Examples of standardized organizational tools for report include - SBAR, ISBAR, BATON, Five P’s, IPASS
What components about the client are includes in report?
Client’s name, doctor, date of admission and diagnosis
Any unresolved / uncompleted tasks
Priorities, abnormal results, fluid status (intake and output)
Significant information on status/condition
Client’s response to care/treatment
consults/referrals
Changes in plan of care
Anything unusual or special treatments
What is included in the use of documents to record and communicate client information?
Documentation is a form of written communication
Facilities have their own documentation methods and forms
Needs to be complete, accurate and timely
Allows interdisciplinary exchange of information
Provides evidence of legal responsibilities, demonstrates standards
Supplies information for cost-to-benefit reduction analysis
Furnished information for research, continuing education, risk management, reimbursement, quality improvement
What can lead to documentation errors?
Omissions of information
Personal opinions (should always be objective or direct statement of client)
vague/abbreviations
Late entries
Improper corrections
Illegibility, lack of clarity
Omission of reasoning for drug administration not completed as ordered
– Must chart why a drug is not administered
Describe abbreviation use in documents?
Only accepted and approved abbreviations should be used
All facilities are required to have formalized list of unacceptable abbreviations
- May be misinterpreted
- Leads to errors and and confusion
Joint Commision on Accreditation of Healthcare Organizations is a guide for these
Continuity of care: perform procedures necessary to safely admit, transfer or discharge a client
Admission and discharge should always be completed by RN
Admission and transfer – client is assessed and plan of care is started by receiving nurse
Admission process includes orienting client and support system to setting, complete review of bio-psycho-social status and needs, med.
Reconciliation, complete assessment, give information on HIPAA, client rights and responsibilities
Sending area of transfer provides a complete report. May have transfer form to complete
Discharges - sender insures discharge is appropriate for client, sharing of information to receiver if applicable
Discharge planning starts before admission for planned admission or at the moment of admission for unplanned admission
What should nurse do if there are unresolved issues?
Never leave unresolved
Report unresolved issues following chain of command
Team nursing
RN leads staff that care for a specific number of clients
Team = RN, LPN, UAP
Team lead assesses and makes plan of care
Team lead assigns tasks to team as needed
Modular nursing
RN is paired with LPN to provide care to small group of clients
Primary nursing
RN plans and organizes care for group of client entire hospitalization
RN assumes 24 hour accountability and delegates care in their absence
Nurse delegated to is called associate nurse
Total client care nursing
RN plans, organized, delivers care for a specific group of clients
Functional nursing
Each caregiver is given specific tasks
Establishing priorities
actual problems/needs take priority over wellness or possible risk
→ short term acute needs take priority over long term chronic needs
How should a nurse prioritize who she treats first?
ABC’s = airway, breathing and cardiovascular status is the highest priority, IN THAT ORDER
Only exception is during CPR, then CAB
How should a nurse prioritize Maslows Hierarchy of needs?
Physiological - ABCs, nutrition, sleep, elimination
safety/psychological/emotional needs - low stress/anxiety, emotion support, comfort
Need for loving and belonging - acceptance of others
Need for self esteem - recognized and respected
Need for self-actualization - motivate to reach highest potential
If a physiological need is not addresses then look for safety
How can a nurse apply knowledge when establishing priorities for interventions with multiple clients
utilize the nursing process (asses, analyze, plan, implement, evaluate)
however, in an emergent situation, the action may take priority over doing an assessment (if someone is bleeding out)
What do we need to remember when prioritizing care?
everything is important - we need to determine the correct order of action
- avoid unnecessary interruptions
- avoid helping other if it can jeopardize your own priorities of care
