1. A nurse is describing the purposes of a health care record to a group of

nursing students. Which purposes will the nurse include in the teaching

session? (Select all that apply.)

a. Communication

b. Legal documentation

c. Reimbursement

d. Nursing process

e. Research

f. Education

ANS: A, B, C, E, F

A patient’s record is a valuable source of data for all members of the health

care team. Its purposes include interdisciplinary communication, legal

documentation, financial billing (reimbursement), education, research,

and auditing/monitoring. Nursing process is a way of thinking and

performing nursing care; it is not a purpose of a health care record.

2. A nurse is developing a plan to reduce data entry errors and maintain

confidentiality. Which guidelines should the nurse include? (Select all

that apply.)

a. Bypass the firewall.

b. Implement an automatic sign-off.

c. Create a password with just letters.

d. Use a programmed speed-dial key when faxing.

e. Impose disciplinary actions for inappropriate access.

f. Shred papers containing personal health information (PHI).

ANS: B, D, E, F