Documentation & Legal Standards Flashcards

Which federal law protects the privacy of a patient's vascular access records and limits disclosure of protected health information?

Answer: HIPAA

HIPAA's Privacy Rule governs use and disclosure of protected health information, including vascular access documentation.

After a needlestick from a used catheter stylet, the nurse should document and report the exposure primarily to comply with:

Answer: The OSHA Bloodborne Pathogens Standard

OSHA requires employers to maintain exposure documentation, a sharps injury log, and post-exposure evaluation for bloodborne pathogen exposures.

A power-injectable PICC fractures during a contrast injection. Beyond internal reporting, which reporting pathway applies to this device malfunction?

Answer: Report to the FDA (e.g., MedWatch/MDR process) as required by the Safe Medical Devices Act

The Safe Medical Devices Act requires facilities to report device-related serious injuries or deaths, typically via the FDA's reporting system, and MedWatch accepts voluntary reports of malfunctions.

Which entity defines the legal scope of practice for a registered nurse inserting midline catheters?

Answer: The state Nurse Practice Act and board of nursing

Scope of practice is defined by each state's Nurse Practice Act and board of nursing; professional standards inform but do not grant legal authority.

A nurse documents 'catheter flushed per protocol' but the protocol changed last month. What is the main legal risk?

Answer: It may be unclear which procedure was performed, weakening the record as evidence of care

Vague 'per protocol' charting can fail to show exactly what was done, especially when protocols change, so specific actions and solutions should be documented.

Which element should be included when documenting patient and caregiver education for home CVAD care?

Answer: Content taught, teaching method, who was taught, and evidence of understanding such as return demonstration

Education documentation should show what was taught, to whom, how, and how comprehension was verified, supporting safe transition and legal defensibility.

In an electronic health record, a nurse leaves the workstation logged in and another clinician charts under her credentials. Which principle was violated?

Answer: Individual accountability and security of electronic signatures

Electronic signatures and logins are personal; sharing or leaving them accessible compromises authorship authenticity and record integrity.