Identify the purposes of a health care record. (Select all that ...

[schs14]

Identify the purposes of a health care record. (Select all that apply.)
 
  a. Communication
  b. Legal documentation
  c. Reimbursement
  d. Education
  e. Research
  f. Nursing process

Question 2

A nurse is creating a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)
 
  a. Create a password with just letters.
  b. Bypass the firewall.
  c. Use a programmed speed-dial key when faxing.
  d. Implement an automatic sign-off.
  e. Impose disciplinary actions for inappropriate access.
  f. Shred papers containing personal health information (PHI).

[mk6555]

Answer to Question 1

ANS: A, B, C, D, E
The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record.

Answer to Question 2

ANS: C, D, E, F
When faxing, use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. An automatic sign-off is a safety mechanism that logs a user off the computer system after a specified period of inactivity. An automatic sign-off is used in most patient care areas and other departments that handle sensitive data. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. All papers containing PHI (e.g., Social Security number, date of birth or age, patient's name or address) must be destroyed. Most agencies have shredders or locked receptacles for shredding and later incineration. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information and should not be bypassed.