If an agency is using computer-assisted charting, the nurse is responsible for:
Guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal.
Learning the passwords of the staff nurses and primary care providers so that they can communicate with one another.
Choosing whether he will use the computer to help in documentation or continue to use traditional paper documentation.
Patient education to input information about herself, such as intake and output or symptoms the patient may experience.
The Correct Answer is A
A. Guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal. Protecting patient confidentiality is essential in electronic charting to prevent unauthorized access.
B. Learning the passwords of the staff nurses and primary care providers so that they can communicate with one another. Sharing or learning others' passwords violates security protocols and confidentiality rules.
C. Choosing whether he will use the computer to help in documentation or continue to use traditional paper documentation. In facilities using electronic charting, all staff are typically required to use the system to maintain consistent, accessible records.
D. Patient education to input information about herself, such as intake and output or symptoms the patient may experience. Patients typically do not have access to chart directly into their medical records.
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Correct Answer is C
Explanation
A. Share information with the patient about other patients and why they are hospitalized. Sharing information about other patients violates confidentiality and does not help establish trust. This is unprofessional and goes against HIPAA guidelines.
B. Share his own personal experiences so that the patient gets to know him as a friend. Although occasional sharing of personal experiences may enhance rapport, extensive sharing can shift focus from the patient to the nurse, which is unprofessional and can create boundary issues.
C. Act in a trustworthy and reliable manner; respect the individuality of the patient. Acting in a trustworthy, reliable manner and respecting the patient's individuality establishes rapport by building trust, ensuring the patient feels valued and respected. This is the most professional approach.
D. Identify himself by name and title each time he introduces himself. Introducing oneself by name and title is essential, but it alone does not fully establish rapport. It is part of a courteous approach, but rapport-building requires deeper engagement.
Correct Answer is B
Explanation
A. is packing belongings in preparation for discharge. Although discharge is an appropriate time for patient education, it may be too late to introduce complex information that requires practice or understanding. Teaching moments often occur earlier in the care process.
B. says, "How will I remember all the things about my new diet?" This is an ideal teaching moment as the patient is expressing concern and showing readiness to learn about the diet. The nurse can use this moment to provide guidance on strategies to remember dietary instructions.
C. has just returned from surgery for a deviated septum. Immediately post-surgery, the patient may be under the influence of anesthesia or pain medication, limiting their ability to absorb information. Teaching at this time may not be effective.
D. has just been told of the malignancy of his tumor. Right after receiving bad news, patients may experience shock, grief, or distress, making it difficult for them to process additional information. This may not be the right time for education.