SGNA Documentation and Legal Issues

Question 1

Which element is NOT required in a complete informed consent for endoscopy?

Accepted Answer

Patient's insurance information

Answer

Procedure risks and benefits

Answer

Alternative treatment options

Answer

Right to refuse the procedure

Question 2

What does HIPAA primarily protect in the healthcare setting?

Accepted Answer

Patient health information privacy and security

Answer

Hospital billing practices

Answer

Nurse licensing requirements

Answer

Medical equipment standards

Question 3

When documenting an endoscopy procedure, which finding must always be recorded in the procedure note?

Accepted Answer

Quality indicators including cecal intubation and withdrawal time

Answer

Patient's insurance provider

Answer

Nursing staff social security numbers

Answer

Hospital administration comments

Question 4

A patient refuses a recommended colonoscopy after being fully informed of the risks. The nurse should:

Accepted Answer

Document the refusal and the information provided to the patient

Answer

Convince the patient using emotional pressure

Answer

Schedule the procedure anyway

Answer

Contact the patient's family to override the decision

Question 5

What is the standard of care for documenting medication administration errors in GI nursing?

Accepted Answer

Document accurately in the patient record and complete an incident report

Answer

Document only in the incident report, not the patient record

Answer

Do not document unless patient is harmed

Answer

Notify the patient's family first, then document

Question 6

The medical record is considered a legal document. What should a nurse do if a documentation error is discovered?

Accepted Answer

Draw a single line through the error, write 'error,' initial and date, then add the correct entry

Answer

Use correction fluid (white-out) to cover the error

Answer

Delete the entry if it is electronic

Answer

Leave the error and make no correction