Author Question: The nurse works at an organization that is installing a new computerized record system. What should ... (Read 24 times)

Capo · **on:** Jul 23, 2018

The nurse works at an organization that is installing a new computerized record system. What should the nurse learn that has been implemented to help ensure the security of client records?

1. A firewall to protect the server from unauthorized access
2. One unit password to protect the unit's information
3. Expectation to log off a terminal after using it
4. Expectation to turn the monitor away from view when unattended
5. Requirement to shred all computer-generated worksheets

Question 2

A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux.

Which problem with documentation might have caused the lack of reimbursement?
1. The client's record contained an incorrect DRG.
2. The client was charged for an ECG.
3. A code cart was opened and the client was charged for medications opened but not used.
4. The physician made a diagnostic mistake.

adammoses97 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 1, 3, 5
Rationale 1: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Guidelines for confidentiality and security of computerized records include the installation of a firewall to protect from unauthorized access.
Rationale 2: Guidelines for confidentiality and security of computerized records include assignment of a personal password to enter and log off computer files. The password should not be shared with anyone, including other team members.
Rationale 3: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. The nurse should learn to never leaving a monitor unattended after logging on.
Rationale 4: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Turning the monitor away from view is not a sufficient safeguard.
Rationale 5: The Security Rule of HIPAA became mandatory in 2005 and governs the security of electronic protected health information. Guidelines for confidentiality and security of computerized records include shredding all confidential information.

Answer to Question 2

Correct Answer: 1
Rationale 1: Documentation helps a facility receive reimbursement from the federal government. The client's clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the appropriate care has been given. Coded diagnoses, such as DRGs, are supported by accurate, thorough recording by nurses.
Rationale 2: This would not necessarily result in the problem related to reimbursement because it is a reasonable diagnostic test to perform in this situation.
Rationale 3: This would not necessarily result in the problem related to reimbursement.
Rationale 4: This would not necessarily result in the problem related to reimbursement.