A nurse documents the following in Mrs. Chapman's chart after an altercation with another patient: Mrs. Chapman was pushed to the floor by Mrs. Smith at 1500 hrs, witnessed by this RN. Mrs. Chapman has been increasingly intrusive with other clients recently. She was assessed and has no bruises or deformities and reports no pain. Vital signs were normal. Patient was not on fall precautions and reports no dizziness. A&O x3. Dr. Mott and DPOA Bob Chapman notified at 1545 hrs. No further orders.
Which part of the documentation indicates a violation of confidentiality?
Explanation
•The violation of confidentiality was the inclusion of the name of other patient involved: "Mrs. Chapman was pushed to the floor by Mrs. Smith at 1500 hrs, witnessed by this RN".
•Documentation of an incident involving two patients in a patient chart should never name the other patient involved, only objective information about the incident. This is an HIPAA violation.
•The incident report may name both patient, but not a patient's medical record.
•Assess the patient and record bruises, lacerations, pain, or deformity. Record vital signs and mental status. Document who was notified and any orders given like fall precautions. Also document any patient education.
Incorrect options:
•"Mrs. Chapman has been increasingly intrusive with other clients recently." This is appropriate documentation that should be noted since it may indicate a change in mental status.
•"POA Bob Chapman notified." This is appropriate documentation. The name of the DPOA is not confidential and it is appropriate to inform this person and to document that.
•"Dr. Mott notified." This is appropriate documentation.