NSG 321 Documentation (Complete And Verified Study material) (8pages) LEARNEXAMS

1. Patient Record: Answer - compilation of a patient's health information - only permanent legal document that goes into detail about nurse's interaction with patient. 2. Purpose of Records: Answer -Communication between disciplines -legal documentation -financial billing -education -research -auditing/monitoring 3. EHR: Answer electronic health record 4. Benefits of EHR: Answer -has immediate access for nurses, physicians, etc. -no lost records 5. HIPPAA: Answer - right to privacy - Health Insurance Portability and Accountability Act - access to the patient record is restricted to those in the facility using it for care.