Documentation and Interprofessional Communication
Documentation and Interprofessional Communication ( 5 Questions)
A nurse is preparing to document a client's care in the electronic health record. Which action should the nurse take to ensure confidentiality and security of the client's information?
Use a personal identification number (PIN) to access the system. - This is a correct action, but not the best answer, as using a PIN alone does not ensure confidentiality and security of the client's information. The nurse should also log out of the system after completing the documentation.
Share the PIN with another nurse who needs to update the record. - This is an incorrect action, as sharing the PIN with another nurse violates the client's privacy and compromises the security of the system. The nurse should never share the PIN with anyone, and each nurse should use their own PIN to access and document in the record.
Log out of the system after completing the documentation.
Rationale: The nurse should log out of the system after completing the documentation, as this prevents unauthorized access to the client's information by other users. Logging out also ensures that the nurse's name and time stamp are accurate for each entry.
Leave the computer screen on while attending to another client. - This is an incorrect action, as leaving the computer screen on while attending to another client exposes the client's information to anyone who can view the screen. The nurse should log out of the system or lock the screen before leaving the computer.
Correct answer: C) Log out of the system after completing the documentation.
Rationale: The nurse should log out of the system after completing the documentation, as this prevents unauthorized access to the client's information by other users. Logging out also ensures that the nurse's name and time stamp are accurate for each entry.
Incorrect options:
A) Use a personal identification number (PIN) to access the system. - This is a correct action, but not the best answer, as using a PIN alone does not ensure confidentiality and security of the client's information. The nurse should also log out of the system after completing the documentation.
B) Share the PIN with another nurse who needs to update the record. - This is an incorrect action, as sharing the PIN with another nurse violates the client's privacy and compromises the security of the system. The nurse should never share the PIN with anyone, and each nurse should use their own PIN to access and document in the record.
D) Leave the computer screen on while attending to another client. - This is an incorrect action, as leaving the computer screen on while attending to another client exposes the client's information to anyone who can view the screen. The nurse should log out of the system or lock the screen before leaving the computer.