Report
When receiving a telephone order from a provider, the nurse should always _____ before hanging up?
read the order back to the provider to confirm it is correct
What form of documentation is used to chart routine assessments or interventions such as vital signs, medications, and I&Os.
What is a flow sheet
What ethical principle requires nurses to tell the truth and provide accurate information to patients?
What is veracity
This structured technique ensures the sender’s message is repeated back by the receiver and confirmed again before the task is carried out, reducing communication errors.
What is closed-loop communication?
What federal law was created in 1996 that protects patient information and ensures confidentiality in all healthcare settings?
What is HIPPA (Health insurance portability and accountability act
Structured communication tool used to standardize handoff?
What is SBAR
What are the two main documentation formats?
What are narrative charting and formatted charting
What are the three ethical principles that guide nurses when distributing resources fairly, preventing harm, and doing good?
What are justice, nonmaleficence, and beneficence
This standardized hand-off format includes Illness severity, Patient summary, Action list, Situational awareness & contingency planning, and Synthesis by receiver.
What is I-PASS?
Which two major rules of HIPAA govern how patient information is protected and how data security must be determined?
What is Privacy rule and security rule
The nurse is giving handoff using SBAR. Which statement represents the “A” (Assessment)?
“The patient’s oxygen saturation is 88%…”
Should medical records contain facts or opinions?
What are facts
This ethical requirement must always be obtained before any procedure, ensuring that the patient understands risks, benefits, and alternatives.
What is informed consent
This national patient-safety communication model is essential in nursing practice because it improves teamwork, reduces preventable medical errors, enhances patient outcomes, and strengthens safety culture across interprofessional teams.
What is TEAMSTEPPS
HIPAA supports this ethical principle by ensuring that patient information is kept confidential and used only for the patient’s benefit.
What is Beneficence
What is the primary purpose of handoff communication?
Ensure continuity and safety of care.
After completing an assessment, the nurse sits down to chart. The nurse only documents findings that were abnormal. What method of documentation is the nurse using?
What is charting by exception
A competent adult patient refuses life saving surgery. Respecting this decision demonstrates which ethical principle?
What is autonomy
A nurse thinks “I assessed the patients pain, mobility, and vital signs and I verbally updated the team- do I really need to chart every detail in the EHR?” TeamSTEPPS and legal guidelines would respond with this widely-known documentation rule.
What is “if it wasn’t documented, it never happened”
If a nurse overhears staff discussing a patient in the hallway, according to HIPAA, this is considered a violation of this concept
What is Violation of protected health information (PHI)
A medication error occurred during the previous shift, and the patient now shows mild hypotension. The nurse suspects the previous nurse did not report the error. Which action is MOST appropriate?
Complete an incident report and notify the provider
During med pass, a patient refuses to take their stool softener. Where would the nurse document this?
What is the medication administration record (MAR)
A nurse is assigned too many patients and believes safe care can not be maintained. What is the ethical response?
What is advocating for safe staffing or reporting unsafe conditions
A nurse performs a full assessment but only reports it verbally instead of documenting it in the EHR. This action risks communication errors and impacts patient safety because it violates this key expectation.
What is the requirement to document everything?
A nurse receives a text from a coworker asking for updates on a mutual friend. Under HIPAA, the nurse should respond how?
Decline to disclose information and remind the coworker that PHI cannot be shared without authorization