IL Final Exam
HIPAA (1996) Health Insurance Portability and Accountability Act: ANS: sets rules to limit who may have
access to a patient's health information
- any details that can identify a patient must be protected (SSN, DOB, name, phone number, etc ---> PHI
- protected health information)
- gives patients the right to access and change their records
- info must be shredded
The Joint Commission does what relating to HIPAA? ANS: mandates the use of computerized databases
to expedite the accreditation process.
Information Security ANS: - A major component of HIPAA, the privacy rule
- Healthcare providers that are caring for the patient should be the only people accessing their
information.
- Essential for nurses to be aware of client's rights to privacy and confidentiality
Privacy Rule ANS: a part of HIPAA that requires that nurses protect all written and verbal communication
about clients
Information Security Protocol ANS: - log off from the computer before leaving the workstation
- Never share a user ID or password (not even with IT)
- Never leave a medical record or other printed documents where others can access it
- Shred any printed or written client information
Levels of Prevention ANS: Primary Prevention
Secondary Prevention
,Tertiary Prevention
Primary Prevention ANS: focuses on health promotion and illness prevention
- attempt to avoid development of disease as much as possible & remove risk factors
EX: Healthy People 2020, Immunizations, Tobacco use/smoking cessation
Secondary Prevention ANS: include the diagnosis and treatment of disease
- attempts to prevent progression of the disease
EX: screenings, annual mammograms
Tertiary Prevention ANS: the restoration of health following an illness or accident and includes
rehabilitation and palliative services
- decreasing disease-related complications
EX: physical therapy to regain mobility
Levels of Care ANS: Primary Health Care
Secondary Health Care
Tertiary Health Care
Primary Health Care ANS: emphasizes health promotion
- a sustained partnership between clients and providers
EX: office and clinic visits, work and school screenings
Secondary Health Care ANS: the diagnosis and treatment of acute illness and injury
EX: hospital settings; diagnostic centers; urgent and emergency care centers
, Tertiary Health Care ANS: the provision of specialized and highly technical care
EX: intensive care; oncology centers; burn centers
Nursing Process ANS: Consists of five steps to follow in a purposeful, goal-directed, systemic way to
achieve optimal client outcomes
The Nursing Process: ANS: 1. Assessment
2. Diagnosis/Analysis
3. Planning
4. Implementation
5. Evaluation
The Nursing Process: Assessment ANS: collecting, organizing, validating, and documenting client data
- subjective(what patient says.. meds, history) and objective data collection(Nurse observes... VS/ I&O)
Includes: initial assessments, interviews, medical history, or a physical examination
Diagnosis/Analysis ANS: identify health problems, risks, and strengths
- clustering of assessment data
- formulate diagnostic statements based on nursing judgement, not the medical diagnosis
A nursing Diagnosis ANS: a statement based on the nurses judgement
- describes the human response (what's going on)
- changes when the patient's response changes (not static)
- involves independent nursing functions
Medical Diagnosis ANS: made by a physician and refers to a disease process
HIPAA (1996) Health Insurance Portability and Accountability Act: ANS: sets rules to limit who may have
access to a patient's health information
- any details that can identify a patient must be protected (SSN, DOB, name, phone number, etc ---> PHI
- protected health information)
- gives patients the right to access and change their records
- info must be shredded
The Joint Commission does what relating to HIPAA? ANS: mandates the use of computerized databases
to expedite the accreditation process.
Information Security ANS: - A major component of HIPAA, the privacy rule
- Healthcare providers that are caring for the patient should be the only people accessing their
information.
- Essential for nurses to be aware of client's rights to privacy and confidentiality
Privacy Rule ANS: a part of HIPAA that requires that nurses protect all written and verbal communication
about clients
Information Security Protocol ANS: - log off from the computer before leaving the workstation
- Never share a user ID or password (not even with IT)
- Never leave a medical record or other printed documents where others can access it
- Shred any printed or written client information
Levels of Prevention ANS: Primary Prevention
Secondary Prevention
,Tertiary Prevention
Primary Prevention ANS: focuses on health promotion and illness prevention
- attempt to avoid development of disease as much as possible & remove risk factors
EX: Healthy People 2020, Immunizations, Tobacco use/smoking cessation
Secondary Prevention ANS: include the diagnosis and treatment of disease
- attempts to prevent progression of the disease
EX: screenings, annual mammograms
Tertiary Prevention ANS: the restoration of health following an illness or accident and includes
rehabilitation and palliative services
- decreasing disease-related complications
EX: physical therapy to regain mobility
Levels of Care ANS: Primary Health Care
Secondary Health Care
Tertiary Health Care
Primary Health Care ANS: emphasizes health promotion
- a sustained partnership between clients and providers
EX: office and clinic visits, work and school screenings
Secondary Health Care ANS: the diagnosis and treatment of acute illness and injury
EX: hospital settings; diagnostic centers; urgent and emergency care centers
, Tertiary Health Care ANS: the provision of specialized and highly technical care
EX: intensive care; oncology centers; burn centers
Nursing Process ANS: Consists of five steps to follow in a purposeful, goal-directed, systemic way to
achieve optimal client outcomes
The Nursing Process: ANS: 1. Assessment
2. Diagnosis/Analysis
3. Planning
4. Implementation
5. Evaluation
The Nursing Process: Assessment ANS: collecting, organizing, validating, and documenting client data
- subjective(what patient says.. meds, history) and objective data collection(Nurse observes... VS/ I&O)
Includes: initial assessments, interviews, medical history, or a physical examination
Diagnosis/Analysis ANS: identify health problems, risks, and strengths
- clustering of assessment data
- formulate diagnostic statements based on nursing judgement, not the medical diagnosis
A nursing Diagnosis ANS: a statement based on the nurses judgement
- describes the human response (what's going on)
- changes when the patient's response changes (not static)
- involves independent nursing functions
Medical Diagnosis ANS: made by a physician and refers to a disease process
