Legal Basics
This law protects patient health information privacy.
What is Health Insurance Portability and Accountability Act?
Charting after the fact but clearly labeling time and reason is called this.
What is a late entry?
Looking up a pt’s chart without being assigned to them is this.
What is a HIPAA violation?
This organization ties reimbursement to documentation quality.
What is Centers for Medicare & Medicaid Services?
Scanning meds outside the pt room is an example of this.
What is a workaround?
This act promoted EHR adoption and increased penalties for data breaches.
What is HITECH Act?
Copying & pasting previous notes w/o verification is this risky practice
What is copy-forward charting?
Posting pt info (even without a name) on social media can result in this.
What is termination or legal action?
This organization sets national patient safety goals.
What is The Joint Commission?
Ignoring a clinical alert and causing harm may result in this.
What is nurse liability?
“If it’s not documented, it wasn’t done” refers to this legal concept.
What is documentation as legal evidence?
This type of wording is risky: “patient doing fine.”
What is vague/non-specific documentation?
The minimum necessary rule means this.
What is only accessing information needed for care?
This initiative encouraged meaningful use of EHRs.
What is Promoting Interoperability (Meaningful Use)?
Bar-code med administration improves this “right.”
What is the right patient/right medication?
This tracks every click, entry, and access in the EHR.
What is an audit trail?
The most important thing to include after a patient fall.
What is a thorough assessment (neuro, injuries, vitals)?
RN accesses her neighbor’s chart out of curiosity. Legal or illegal
What is illegal (HIPAA violation)?
Policies requiring barcode scanning are designed to prevent this.
What are medication errors?
Even if technology fails, responsibility ultimately falls on this.
What is the nurse’s clinical judgment?
Documenting something you didn’t actually do is considered this.
What is falsification of records?
Failing to document provider notification after a critical event can lead to this.
What is legal liability/negligence?
Nurse charts vitals she forgot to take.
What is falsification?
Health policy primarily influences nursing informatics by affecting this.
What is documentation requirements and workflows?
Nurse delays charting a critical event for hours.
What is late documentation with legal risk?