which of the following components of the written "patient care report is considered confidential"

What documentation does the nurse provide for the patient?

The nurse also documents the time and content of two calls made to the patient's primary care provider requesting that the primary care provider examines the patient for unexpected complications. This documentation by the nurse is likely to:

How does the nurse use the flow sheet in patient care documentation?

The nurse uses the flow sheet in patient care documentation primarily: a. to track routine assessments, treatments, and frequently given care. b. to eliminate written narratives and to save time.

What data should be included in a patient portal?

patient data, including patient's name, address, phone number, insurance company, and admitting diagnosis.

What are the exceptions to the confidentiality of medical records?

Confidentiality is subject to certain exceptions because of legal, ethical, and social considerations. When patients are at risk of physically harming another person, or if those patients are at risk of harming themselves, the physician has the legal obligation to protect the potential victim and notify law enforcement authorities.

When a patient refuses a treatment, should the nurse document the exact words of the patient regarding why the patient?

When a patient refuses a treatment, the nurse should document the exact words of the patient regarding why the patient is refusing care.

When documenting a sign or symptom, should the nurse include the quality (levels 7 to 8), chrono?

When documenting a sign or symptom, the nurse should include the quality (levels 7 to 8), chronology ( after lunch, last 3 hours), and aggravating or alleviating factors, as well as associated symptoms.

What to say to a resident in a skilled nursing facility after hip replacement?

A resident in a skilled nursing facility for a short term rehabilitation following a hip replacement says to the nurse, "I don't want to have you draw any more blood for those useless tests.". When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be: a.

Why does the doctor black out the note?

blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time.

What is the nurse's document?

The nurse also documents the time and content of two calls made to the patient's primary care provider requesting that the primary care provider examines the patient for unexpected complications. This documentation by the nurse is likely to: a.

What is documentation in insurance?

Documentation also serves as evidence of standards of care in a court of law. 2.

What does "subjective" mean in a medical record?

In a medical record for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives, the nurse documents "Subjective: denies itching. Happy with improvement in skin.

Which principle is most closely associated with the concept of self-determination?

autonomy . The basic principle that is most closely associated with the concept of self-determination. autonomy. "Nurses should practice nursing and allied health specialists should only practice within their specialty areas" in an application of what principle.

Do clients have the right to believe that health care professionals are struggling incessantly on their behalf?

Clients have the right to believe that health care professionals are struggling incessantly on their behalf. This is the application of the principle

Who can have access to patients' medical records?

Most notably, they can exist between patients, any medical caregiver, hospitals, laboratories, insurers and even secretarial help and housekeepers that may have access to patients or their medical records. It is not possible in this article to list all of patient's rights.

What are the rights of patients?

Patients have rights in a medical setting, including the right to care and the right to refuse treatment, among other important protections. Patient rights are those basic rule of conduct between patients and medical caregivers as well as the institutions and people that support them. A patient is anyone who has requested to be evaluated by ...

What is a patient caregiver?

A patient is anyone who has requested to be evaluated by or who is being evaluated by any healthcare professional. Medical caregivers include hospitals, healthcare personnel, as well as insurance agencies or any payors of medical-related costs.

What is informed consent in medicine?

Part of communication in medicine involves informed consent for treatment and procedures. This is considered a basic patient right. Informed consent involves the patient's understanding of the following: What the doctor is proposing to do. Whether the doctor's proposal is a minor procedure or major surgery.

What is the role of a physician in the patient relationship?

Open and honest communication is an integral part of the doctor-patient relationship. The AMA's Code of Medical Ethics clearly states that it is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients. Patients have a right to know their past and present medical status and to be free of any mistaken beliefs concerning their conditions. Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician's mistake or judgment. In these situations, the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred. Only through full disclosure is a patient able to make informed decisions regarding future medical care.

Why can't a patient make a competent decision?

Patients with an altered mental status because of alcohol, drugs, brain injury, or medical or psychiatric illness may not be able to make a competent decision; then the patient may need to have a person legally appointed to make medical decisions.

What are the basic rights of an emergency patient?

Some basic rights are that all patients that seek care at an emergency department have the right to a screening exam and patients that cannot afford to pay are not turned away. The details of these rights are detailed in the Emergency Medical Treatment and Active Labor Act (EMTALA) laws in the U.S.