A nurse is working in an agency that uses EHR for documentation.

Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information?

(Select all that apply.).

Use a personal password to access the system and log off when finished.

Share the password with other nurses who need to access the system.

Print out a copy of the client’s record and store it in a locked cabinet.

Report any breaches or attempted breaches of security to the appropriate personnel.

Delete any information that is incorrect or outdated from the system.

Answer and Explanation

Correct Answer : A,D

The nurse should use a personal password to access the system and log off when finished, and report any breaches or attempted breaches of security to the appropriate personnel.

These actions ensure confidentiality and security of the client’s information by preventing unauthorized access and disclosing any violations.

Choice B is wrong because sharing the password with other nurses who need to access the system violates the principle of minimum necessary access, which means that only those who need the information for a specific purpose should have access to it.

Choice C is wrong because printing out a copy of the client’s record and storing it in a locked cabinet creates a risk of loss, theft, or unauthorized disclosure of the paper record. The nurse should avoid printing out electronic health records unless absolutely necessary, and should follow the proper disposal procedures if they do.

Choice E is wrong because deleting any information that is incorrect or outdated from the system may compromise the integrity and availability of the client’s information. The nurse should follow the established policies and procedures for correcting or updating electronic health records, which may include adding an addendum or annotation to the original entry, but not deleting it.

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Correct Answer is C

Explanation

It reduces duplication of documentation among caregivers.

This is an advantage of using an EHR system because it allows different healthcare providers to access and update the same record, avoiding unnecessary repetition and inconsistency.An EHR system also improves the quality and safety of care by providing clinical decision support, reducing medication errors, and facilitating communication among caregivers.

Choice A is wrong because it is not the only advantage of using an EHR system.While it is true that an EHR system eliminates errors due to illegible handwriting, it may also introduce new types of errors such as data entry mistakes, system failures, or unauthorized access.

Choice B is wrong because it is not an advantage of using an EHR system.

In fact, it may be a disadvantage because it poses a risk to the confidentiality and security of the clients’ records.An EHR system should have built-in safeguards to protect the privacy and integrity of the data, such as encryption, passwords, and audit trails.

Choice D is wrong because it is not an advantage of using an EHR system.It is a requirement of any health record system, whether electronic or paper-based, to comply with the ethical and legal standards of confidentiality.

An EHR system does not provide any additional safeguards that are not already present in a paper-based system.

Normal ranges for vital signs are as follows:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: less than 120/80 mm Hg.

A. Daily weight, blood pressure, and pulse B. Medication administration record. C. Nursing diagnosis and care plan. D. Discharge planning and referral summary.

Correct Answer is A

Explanation

Daily weight, blood pressure, and pulse.

A flow sheet is a type of document that records specific information in a structured and concise way, such as vital signs, fluid intake and output, pain level, etc.A flow sheet is useful for clinical communication and tracking the patient’s condition over time.A medication administration record (MAR) is a separate document that records the medications given to the patient, the dosage, the route, and the time.A nursing diagnosis and care plan is a document that identifies the patient’s problems and goals, and the interventions to achieve them.A discharge planning and referral summary is a document that outlines the patient’s needs and resources after leaving the facility, such as follow-up appointments, home care services, etc.

These documents are not part of a flow sheet.

Choice B is wrong because a MAR is not a flow sheet.

Choice C is wrong because a nursing diagnosis and care plan is not a flow sheet.

Choice D is wrong because a discharge planning and referral summary is not a flow sheet.

Normal ranges for daily weight vary depending on the patient’s age, height, gender, and medical condition.However, a general guideline is that a weight gain or loss of more than 2 kg (4.4 lbs) in a week or 0.9 kg (2 lbs) in a day may indicate fluid retention or dehydration.Normal ranges for blood pressure are less than 120/80 mmHg for adults, and less than 95/65 mmHg for children.Normal ranges for pulse are 60 to 100 beats per minute for adults, and 70 to 120 beats per minute for children.

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A nurse is working in an agency that uses EHR for documentation. Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information? (Select all that apply.).

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A nurse is working in an agency that uses EHR for documentation.

Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information?

(Select all that apply.).