RPN Documentation and Reporting 3 — Questions and Answers
Question 1: Under HIPAA, which of the following actions by a nurse would constitute a privacy violation?
- Discussing a patient's care with the treating physician
- Sharing a patient's diagnosis with a family member without the patient's consent (Correct answer)
- Documenting care in the electronic health record
- Reporting a communicable disease to the public health department
Correct answer: Sharing a patient's diagnosis with a family member without the patient's consent
HIPAA prohibits sharing patient health information with family members without explicit patient authorization, with limited exceptions.
Question 2: Which component of the SBAR communication tool prompts the nurse to state what they think is the problem?
- Situation
- Background
- Assessment (Correct answer)
- Recommendation
Correct answer: Assessment
The 'Assessment' component of SBAR is where the nurse provides their clinical judgment about what is happening with the patient.
Question 3: A patient's medical record is subpoenaed for a legal case. The nurse should:
- Alter the record to reflect better care before submitting it
- Submit the record as-is without alteration and notify the facility's legal counsel (Correct answer)
- Refuse to release any records under any circumstances
- Delete electronic entries that seem unfavorable
Correct answer: Submit the record as-is without alteration and notify the facility's legal counsel
Records must never be altered when subject to legal proceedings; the nurse should follow facility policy and notify legal counsel.
Question 4: What is the primary purpose of nursing documentation in the medical record?
- To protect the nurse from malpractice lawsuits
- To provide a communication tool for continuity of patient care (Correct answer)
- To satisfy hospital accreditation requirements only
- To document the nurse's workload for staffing purposes
Correct answer: To provide a communication tool for continuity of patient care
The primary purpose of nursing documentation is to communicate patient status and care provided to ensure continuity of care among all providers.
Question 5: Which abbreviation is on The Joint Commission's 'Do Not Use' list due to potential for misinterpretation?
- PRN
- NPO
- U (for units) (Correct answer)
- BID
Correct answer: U (for units)
The abbreviation 'U' for units is on The Joint Commission's Do Not Use list because it can be mistaken for '0' (zero), potentially causing a 10-fold dosing error.
Question 6: A nurse notices that a colleague documented a nursing assessment they did not actually perform. The nurse should:
- Ignore it, as it is the colleague's responsibility
- Falsify their own record to match the colleague's
- Report the falsification through the appropriate chain of command or reporting mechanism (Correct answer)
- Confront the patient about the discrepancy
Correct answer: Report the falsification through the appropriate chain of command or reporting mechanism
Falsifying medical records is illegal and unethical; the nurse has a professional duty to report such misconduct through proper channels.
Question 7: When documenting a patient's refusal of a prescribed treatment, the nurse must include:
- Only the fact that the patient refused
- The refusal, education provided, patient's stated reason, and notification of the physician (Correct answer)
- A statement that the patient is non-compliant and difficult
- Nothing, as refusals should not be documented
Correct answer: The refusal, education provided, patient's stated reason, and notification of the physician
Complete documentation of refusals includes the patient's reason, teaching provided, and physician notification to demonstrate respect for autonomy and protect the care team.
RPN Documentation and Reporting 3
Under HIPAA, which of the following actions by a nurse would constitute a privacy violation?