Privacy Please
This federal act became effective in 2003 and protects patient privacy and health information
What is HIPAA?
If a patient doesn't speak English, the only acceptable way to communicate with that patient is with use of this.
What is an interpreter/interpreter device?
This is used to gain access to a patient's medical record
What is user name and password?
Policies and procedures can be found here.
What is the hospital intranet.
According to the 'Safe Medical Device Act', all equipment should be used according to these.
What are manufacturer's instructions.
If a family member would like information about a patient over the phone they must provide this.
What is a PIN?
A nurse who leaves the hospital in the middle of her shift because she is stressed and overwhelmed has committed this.
What is patient abandonment?
These should be avoided when documenting the patient medical record.
What are abbreviations?
This format is used for a transition of care handoff.
What is SBAR?
What are annual competencies?
Emails containing PHI should be encrypted and marked with this in the subject line.
What is SECURE?
This division of the Department of Health could is responsible for suspending or revoking a nurse's license in the event of litigation.
What is the State Board of Nursing?
This part of the patient record should be objective, factual and judgement free.
What are narrative notes?
Nursing documentation should reflect this.
What is the nursing process?
A nurse could be called to court if she fails to give these to a patient when they depart the hospital.
What are discharge instructions?
If a patient requests a copy of their medical record, they would go here to collect the paperwork.
What is the medical record deparment?
Accidentally administering a smaller dose of medication than was ordered by the physician is considered this.
What is a medication error?
These five steps of the nursing process should be included in all patient documentation.
What is assessment, diagnosis, plan, interventions and evaluation.
Policies and procedures should be created using this type of research/information.
What is Evidence Based Research?
If a patient takes legal action and a nurse is called to share information, the process is called this.
What is a deposition?
Facility specific guidelines for maintaining patient privacy and protecting their health information are found here.
What is policies and procedures?
Legal action may be filed against healthcare workers in these two types of court.
What is civil and criminal courts?
When information is filed in the S.A.F.E. it should never be mentioned here.
What is the patient's medical record?
This policy is centrally important to surgical procedures.
What is Universal Protocol?
Entering into a patient care situation where you lack skills and knowledge to provide safe care can result in this.
What is patient harm?