Understanding Medical Documentation Flashcards

Under HIPAA, a nursing assistant may share a resident's medical information with:

Answer: Only those directly involved in the resident's care who have a need to know

HIPAA requires that protected health information only be shared on a need-to-know basis with care team members directly involved in the resident's treatment.

When using an electronic health record (EHR) system, a nursing assistant should:

Answer: Log out of the system whenever stepping away from the workstation

Logging out prevents unauthorized access to protected health information and ensures that all entries are attributed to the correct user.

A nursing assistant overhears a visitor asking about a resident's diagnosis at the nurses' station. The appropriate action is to:

Answer: Direct the visitor to speak with the charge nurse or social worker

Nursing assistants should direct visitors with questions about diagnosis or medical status to the licensed nurse or appropriate staff member.

In an electronic health record, what does an electronic signature (e-signature) signify?

Answer: That the person who logged the entry takes professional responsibility for the documented information

An e-signature holds the same legal weight as a handwritten signature and indicates the person's professional accountability for the entry.

Which statement about medical records is TRUE under federal and Utah state regulations?

Answer: Residents have the right to access their own medical records upon request

Both HIPAA and Utah law grant residents the right to access and obtain copies of their own medical records.

When a nursing assistant notices an error in the electronic health record entered by another staff member, they should:

Answer: Notify the person who made the error or notify the charge nurse so it can be corrected by the appropriate party

Only the person who made the entry or a supervisor can make corrections in the EHR, following facility policy for error correction.

Which of the following BEST describes the purpose of the minimum data set (MDS) in long-term care documentation?

Answer: A standardized assessment tool used to evaluate resident needs and plan care in Medicare/Medicaid facilities

The MDS is a federally mandated comprehensive assessment tool used in nursing facilities to evaluate residents and guide individualized care planning.