Answer to Question 1
ANS: A, C, D
Access to electronic records requires a user to have system access and verification codes as a measure of security and protection of the patient's privacy. The codes leave an electronic trail of authorized users that can be audited. HIPAA sets the standards on how security and confidentiality of health care information must be maintained. The act also sets the penalties for any breach in security of health care data.
Answer to Question 2
ANS: A, B, E
A standardized nursing terminology is a structured vocabulary that provides a common means of communication among nurses. A standardized language ensures that when a nurse talks about a specific patient problem, another nurse fully understands the problem. An example is the choice between pressure ulcer, decubitus ulcer, and bedsore. Do all nurses in all settings have a shared understanding of these labels for a patient problem? The Nursing Minimum Data Set (NMDS) represents the first attempt to standardize the collection of essential nursing data. These core data, used on a regular basis by most nurses in the delivery of care across settings, provide accurate descriptions of the nursing diagnoses, nursing care, outcomes of care, and nursing resources used. Collected on an ongoing basis, the NMDS enables nurses to compare data across populations, settings, geographic areas, and time. The International Classification for Nursing Practice (ICNP), developed under the auspices of the International Council of Nurses (ICN), provides a standard that facilitates the description and comparison of nursing practice locally, regionally, nationally, and internationally.