Communication and Documentation Flashcards

A client's sister calls the unit asking for an update on the client's condition. The client has not listed her as someone who can receive information. What should the nurse do?

Answer: Politely decline to share information and explain the privacy policy

Under HIPAA, health information can be shared only with people the client has authorized.

A coworker asks to use the nurse's EHR login because hers is locked. What is the nurse's best response?

Answer: Decline and suggest she contact IT to reset her access

Each login is a legal signature, so sharing credentials breaks security and accountability.

A client asks to read their own medical record. How should the nurse respond?

Answer: Explain that the client has a right to access the record and follow facility policy to arrange it

HIPAA gives clients the right to access their health information through the facility's established process.

A client insists on leaving the hospital against medical advice (AMA). Which documentation is most important?

Answer: The risks explained, the client's understanding, notification of the provider, and the signed AMA form or refusal to sign

Thorough AMA documentation shows informed refusal and protects both the client and the facility.

Which documentation is required for a client in physical restraints?

Answer: The reason for restraint, less restrictive alternatives tried, and ongoing assessments at intervals set by policy

Restraint documentation must justify the restraint and show regular monitoring of circulation, skin, and the client's needs, including release criteria.

After teaching a client how to self-inject insulin, which entry best documents that the teaching worked?

Answer: "Client correctly demonstrated drawing up and injecting insulin and stated signs of hypoglycemia using teach-back."

Documenting a return demonstration and teach-back gives objective evidence that learning happened.

A client from a culture where direct eye contact is seen as disrespectful avoids looking at the nurse. What should the nurse do?

Answer: Respect the client's cultural norms and keep communicating without requiring eye contact

Culturally competent care respects nonverbal norms and doesn't mistake them for symptoms.