Answer to Question 1
A
When a patient is discharged from a health care institution, the members of the health care team prepare a discharge summary. A discharge summary provides important information related to the patient's ongoing health problems and need for health care after discharge. You enhance discharge planning when you are responsive to changes in patient condition and involve the patient and family in the planning process. Some health care organizations use standardized care plans for more efficient documentation. These plans, based on the institution's standards of nursing practice, are preprinted, established guidelines used to care for patients with similar health problems. Many health care organizations now have computerized systems that provide concise, summative information in the form of a patient care summary. Flow sheets and graphic records permit concise documentation of nursing information and patient data over time. Records include documentation of routine observations or repeated specific measurements about the patient such as vital signs, intake and output, hygiene, and medication administration.
Answer to Question 2
A
A. An anonymous name assigned under the agency's blackout procedure is used to ensure client safety.
B. Decisions about the use of anonymous names should be based on the need for client safety.
C. PHI (personal health information) is shared on a need-to-know basis; the minimum amount of information necessary to provide care would be shared with staff members.
D. Usual procedures for other clients may not be adequate to ensure the safety of crime victims.
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