HAC Documentation & Reporting Flashcards

What does the abbreviation 'NPO' mean in a patient's care plan?

Answer: Nothing by mouth

NPO (Latin: 'nil per os') means the patient is not permitted to eat or drink anything, typically before surgery or procedures.

When reporting a change in patient condition, the aide should include:

Answer: Specific observations: what was seen, heard, or measured, and when it occurred

Reports should contain factual, specific observations with timing so the nurse can make an accurate clinical assessment without guessing.

A care plan is primarily used by the healthcare team to:

Answer: Guide individualized, consistent care for a specific patient

A care plan outlines individualized goals and interventions so every team member provides consistent, coordinated care tailored to the patient's needs.

Which of the following is an example of a HIPAA violation by a healthcare aide?

Answer: Discussing a patient's diagnosis with a friend outside of work

Discussing a patient's protected health information with anyone outside the care team, including friends or family, is a HIPAA violation regardless of intent.

If a healthcare aide is unsure how to spell a medical term when documenting, they should:

Answer: Look up the correct spelling in a medical dictionary or approved reference

Correct medical terminology is essential for clear communication; incorrect spelling can lead to misinterpretation and errors in patient care.

The purpose of an incident report when a patient falls is to:

Answer: Document the event factually to enable quality improvement and prevent future incidents

Incident reports provide a factual, timely record of adverse events that facilities use to identify patterns and implement safety improvements.