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Ethical and Legal Considerations in Documenting and Reporting

  • Maintain the confidentiality of all patient information.

  • The client's record is also protected legally as a private record of the client's care.

  • Access to the record is restricted to health professionals involved in giving care to the client.

  • The institution or agency is the rightful owner of the client's record.

  • The client has the right to access all information contained within their own record and to have a copy of the original record.

    • Ensuring Confidentiality of Computerized Records

    • A personal password is needed to enter and sign off computer files.

    • Do not share the password with anyone, including other members of the health team.

    • After logging on, never leave a computer unattended.

    • Do not leave client information displayed on the monitor where others may see it.

    • The Information Technology team must install a firewall to protect the server from unauthorized access.

    • Shed all that is NOT needed in computer-generated worksheets.

    • Know the facility's policy and procedure for correcting an entry error.

    • Follow the agency's procedures for documenting sensitive material such as a diagnosis of AIDS.

Questions on Ethical and Legal Considerations in Documenting and Reporting

Correct Answer is C

Explanation

<p>The proper procedure for correcting errors in documentation, such as drawing a single line through the error, writing &ldquo;error&rdquo; above it, initialing and dating it, and writing the correct information.</p> <p>The nurse must never erase, obliterate, or use correction fluid on the record.Destroying or tampering with the record can be considered fraud or negligence and can jeopardize the nurse&rsquo;s license and credibility.</p>

Correct Answer is ["A","D"]

Explanation

<p>Installing a firewall on the personal computer is not enough to prevent unauthorized access.The nurse should also use encryption, antivirus software, and other security measures.</p>

Correct Answer is A

Explanation

<p>The nurse cannot withhold the client&rsquo;s diagnosis from anyone who has a legitimate need to know, such as other health care providers, public health officials, or partner notification services.The nurse has a duty to warn those who are at risk of exposure to HIV from the client, and to comply with the legal requirements for reporting HIV cases to the state health department and CDC.</p>

<p>Ignoring the error and hoping that no one notices it is unprofessional, unethical and potentially dangerous for the patient&rsquo;s care and safety.</p>

<p>The rationale for this right is that the client has the right to know and understand their own health condition and the care they receive from the health care providers.The client&rsquo;s record is a source of information that can help the client make informed decisions about their health and wel
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