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CHPCN(C) practice questions

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Question 1Health information management

Which statement best describes the purpose of a health record in hospice palliative care?

  1. It provides a continuous, documented account of assessments, interventions, and outcomes that supports continuity of care. Correct answer.
  2. It is maintained only when the patient is actively dying.
  3. It serves mainly as a legal shield against family complaints.
  4. It is used primarily to justify billing rather than to guide care.

Explanation

The health record is a clinical and legal tool whose core purpose is continuity of care: it documents assessments, goals, interventions, and responses so that any team member can provide informed, coordinated care. Legal defensibility and reimbursement are secondary consequences, not the primary purpose.

Question 2Health information management

Under typical privacy legislation, which situation permits disclosure of personal health information without the patient's consent?

  1. Posting a de-identified case story on a personal social media account.
  2. Sharing details with a curious neighbor who asks about the patient's prognosis.
  3. Disclosing to a colleague for a purpose unrelated to care.
  4. Reporting a suspected case of a communicable disease to public health authorities as required by law. Correct answer.

Explanation

Privacy laws generally allow disclosure without consent when a statute mandates it, such as mandatory reporting of certain communicable diseases, child abuse, or fitness-to-drive concerns. Disclosures for curiosity, unrelated purposes, or personal social media are not authorized.

Question 3Health information management

A hospice nurse documents a patient's pain score of 8/10 at 08:00, an intervention at 08:15, and a reassessment of 3/10 at 09:00. Which documentation principle does this best illustrate?

  1. Writing narrative summaries at the end of each week
  2. Recording only the patient's subjective statements
  3. Charting by exception only when problems arise
  4. Documenting the full assessment-intervention-evaluation cycle Correct answer.

Explanation

Complete documentation links the problem identified, the action taken, and the outcome measured. Recording the pain score, the intervention, and the follow-up reassessment demonstrates this assessment-intervention-evaluation cycle, which supports safe and accountable care.

Question 4Health information management

Which element is essential when documenting a telephone order from a physician in a hospice record?

  1. The order verbatim, the date and time, the prescriber's name, and the receiving nurse's signature Correct answer.
  2. A summary written from memory at the end of the shift
  3. Only the medication name and dose
  4. The physician's home address

Explanation

Telephone orders must be recorded verbatim, dated and timed, attributed to the prescriber, read back for verification, and signed by the nurse who received them. This creates an accurate, auditable record.

Question 5Health information management

Which of the following is the best example of a protected health identifier that must be safeguarded?

  1. The patient's functional status score
  2. The patient's health region of residence
  3. The patient's date of birth Correct answer.
  4. The patient's preferred language

Explanation

Date of birth is a direct identifier that, combined with other data, can re-identify an individual. Broad geographic region, language preference, and clinical scores alone are generally less identifying.

Question 6Health information management

A patient asks to see their own hospice record. What is the most appropriate response?

  1. Provide only the portions written by the physician.
  2. Refuse because hospice records are confidential.
  3. Ask the family to decide whether access should be granted.
  4. Provide access according to the jurisdiction's health information access law and organizational policy. Correct answer.

Explanation

Patients generally have a legal right to access their own health information, subject to specific exceptions defined by law and organizational policy. The appropriate response is to follow that access process rather than refuse or delegate the decision.

Question 7Health information management

Which statement correctly describes the role of a minimum data set in palliative care reporting?

  1. It is collected only at the time of death.
  2. It replaces the need for narrative clinical notes.
  3. It standardizes core data elements so that outcomes can be compared across programs. Correct answer.
  4. It is optional and has no bearing on quality improvement.

Explanation

A minimum data set defines a standardized collection of core variables, enabling consistent measurement and comparison of outcomes across settings and programs. It complements rather than replaces narrative documentation and is collected throughout care.

Question 8Health information management

Which practice best protects the confidentiality of a shared hospice team mobile device?

  1. Storing patient photos in the device's general gallery
  2. Sharing one login among all team members
  3. Disabling password protection to speed access
  4. Using automatic screen lock and encryption with individual logins Correct answer.

Explanation

Individual logins with automatic screen locking and device encryption limit unauthorized access if a device is lost or shared. Shared logins and unprotected storage undermine accountability and confidentiality.

Question 9Health information management

A hospice aide charts a patient's pain as 7/10, but the nurse's own assessment later that day is 2/10. What is the most appropriate action?

  1. Review the discrepancy with the aide, clarify the assessment, and document the resolution. Correct answer.
  2. Delete the aide's entry so the record looks consistent.
  3. Leave both entries unchanged and take no action.
  4. Report the aide to the regulator immediately.

Explanation

When entries conflict, the team should investigate the discrepancy, clarify what was assessed and when, and document the resolution. Altering or deleting entries compromises record integrity, and immediate regulatory reporting is disproportionate.

Question 10Health information management

A nurse realizes an entry was made in the wrong patient's chart. What is the correct corrective action?

  1. Use correction fluid to remove the entry.
  2. Add a dated, signed addendum noting the error and the correct information. Correct answer.
  3. Rewrite the entire shift's notes in a new chart.
  4. Erase the entry in the electronic system without a trace.

Explanation

Errors are corrected with a dated, signed addendum or correction note that identifies the mistake and states the accurate information, preserving the original entry and audit trail. Physical alteration or silent deletion is prohibited.

Question 11Health information management

Which set of identifiers is most appropriate to confirm patient identity before administering a controlled medication?

  1. Room number and bed position
  2. Diagnosis and physician name
  3. Full name and date of birth, using two identifiers per policy Correct answer.
  4. Patient's appearance and family presence

Explanation

Policies require at least two independent identifiers, commonly full name and date of birth, verified against the record or identification band. Location, diagnosis, and appearance are unreliable and unsafe substitutes.

Question 12Health information management

A family member requests that the patient's diagnosis be withheld from the patient. Which approach best reflects sound information management and ethical practice?

  1. Tell the family that their request cannot be discussed.
  2. Document the request and explore the patient's own information preferences with the team. Correct answer.
  3. Refuse to document the request as it is not clinically relevant.
  4. Immediately record a permanent restriction on all disclosure to the patient.

Explanation

The request should be documented and explored, because competent patients generally hold the right to their own information. The team should assess the patient's expressed preferences and cultural context before agreeing to any restriction.

Question 13Health information management

Which documentation practice best supports continuity of care across shifts in a hospice residence?

  1. Documenting at the end of the week to capture the full picture
  2. Relying on verbal reports without written backup
  3. Recording only abnormal findings to save time
  4. Using a structured handover summary linked to the care plan goals Correct answer.

Explanation

A structured handover summary tied to documented care plan goals ensures that essential information, priorities, and pending actions transfer accurately between shifts. Verbal-only or delayed documentation increases the risk of omissions.

Question 14Health information management

A hospice program wants to use aggregated patient data for quality improvement. Which step is most important before analysis?

  1. Publishing raw records internally without restriction
  2. De-identifying or aggregating data so individuals cannot be re-identified Correct answer.
  3. Removing all clinical variables from the dataset
  4. Obtaining consent from every deceased patient

Explanation

Secondary use of health data for quality improvement requires that data be de-identified or aggregated to prevent re-identification, in line with privacy law and governance policy. Removing clinical variables would defeat the analysis, and deceased patients cannot consent.

Question 15Health information management

Which statement about audit trails in an electronic health record is accurate?

  1. Audit trails are optional features that most systems omit.
  2. Audit trails record who accessed or changed data and when. Correct answer.
  3. Audit trails can be edited by any clinician to hide errors.
  4. Audit trails apply only to billing information.

Explanation

Audit trails automatically log access and changes with user identity and timestamps, supporting accountability, security investigations, and record integrity. They are not optional and cannot be altered by clinicians.

Question 16Health information management

A patient lacks decision-making capacity and has no documented substitute decision-maker. What is the most appropriate information management action?

  1. Ask the patient's employer to designate a decision-maker.
  2. Withhold all information from everyone until a court order is obtained.
  3. Follow the jurisdiction's hierarchy for substitute decision-making and document who is authorized. Correct answer.
  4. Disclose all information freely to any relative who asks.

Explanation

When capacity is absent, the jurisdiction's legislated hierarchy identifies who may act as substitute decision-maker and receive information. Documenting that authority ensures lawful, accountable information sharing.

Question 17Health information management

Which outcome measure is most appropriate for evaluating the effectiveness of a hospice pain management protocol?

  1. Total pages in the policy manual
  2. Proportion of patients with documented pain reassessment within one hour of intervention Correct answer.
  3. Number of staff meetings held per month
  4. Number of family visits per week

Explanation

A meaningful outcome measure links a process to a clinical result. Documented timely reassessment after intervention reflects whether the pain protocol is being followed and whether patients are being monitored for relief.

Question 18Health information management

What is the primary reason for using standardized nursing terminology in hospice documentation?

  1. To satisfy insurers regardless of accuracy
  2. To increase the length of notes
  3. To replace clinical judgment with codes
  4. To enable consistent data retrieval, comparison, and interoperability Correct answer.

Explanation

Standardized terminology assigns consistent terms and codes to clinical concepts, enabling reliable retrieval, comparison, and exchange of data across systems and settings. It supports, rather than replaces, clinical judgment.

Question 19Health information management

A hospice team discovers that a shared spreadsheet containing patient names and diagnoses is stored on an unsecured personal cloud account. What is the most appropriate immediate action?

  1. Remove the data to an approved secure system, notify the privacy officer, and assess whether a breach occurred. Correct answer.
  2. Delete the file and take no further action.
  3. Continue using it until the end of the quarter.
  4. Share the link only with trusted colleagues.

Explanation

Unauthorized storage of identifiable data is a privacy incident. The team should secure or remove the data, notify the privacy officer, and conduct a breach assessment as required by policy and law. Silent deletion prevents proper assessment and remediation.

Question 20Health information management

Which action best reflects the principle of data minimization in hospice documentation?

  1. Storing extra identifiers in case they become useful later
  2. Recording all family conversations in full detail regardless of relevance
  3. Retaining records indefinitely for potential research
  4. Collecting and retaining only information needed for care, coordination, and legal requirements Correct answer.

Explanation

Data minimization means collecting and keeping only what is necessary for defined purposes such as care, coordination, and legal obligations. Excess collection and indefinite retention increase privacy risk without clear benefit.

Question 21Health information management

A hospice is implementing a new electronic record. Which approach best supports safe adoption?

  1. Disable clinical decision support to reduce alerts
  2. Conduct workflow analysis, role-based training, and a phased go-live with support Correct answer.
  3. Train only the information technology staff and let clinicians learn on the job
  4. Migrate all legacy records without validation

Explanation

Safe implementation involves analyzing clinical workflows, training each role for its tasks, and using a phased go-live with at-the-elbow support. These steps reduce error and disruption during transition.

Question 22Health information management

A patient's record contains conflicting advance care planning documents: an older signed directive and a newer verbal statement to the nurse. How should the team proceed?

  1. Follow the older written directive automatically because it is written.
  2. Ignore both and let the family decide.
  3. Clarify the patient's current wishes where possible, document the discussion, and apply the jurisdiction's rules on validity and recency. Correct answer.
  4. Delete the older directive from the record.

Explanation

Advance care planning documents must be interpreted using the jurisdiction's rules on validity, capacity, and recency, and the patient's current expressed wishes should be clarified and documented. Removing documents or defaulting to family undermines the patient's authority.

Question 23Health information management

Which scenario most clearly constitutes a reportable privacy breach?

  1. A clinician accesses a patient's record to provide direct care.
  2. A pharmacist reviews a medication list for a current patient.
  3. A staff member looks up a celebrity patient's record out of curiosity. Correct answer.
  4. A nurse documents an assessment during a scheduled visit.

Explanation

Accessing a record without a care-related need, such as out of curiosity about a public figure, is unauthorized use and a reportable privacy breach. Legitimate care activities by authorized staff are permitted uses.

Question 24Health information management

A hospice wants to benchmark its symptom outcomes against peer programs. Which data condition is most critical for a valid comparison?

  1. Comparing raw counts of patients rather than rates
  2. Using identical case-mix adjustment and standardized outcome definitions across programs Correct answer.
  3. Allowing each program to define its own outcome measures
  4. Collecting data only from patients who died in the inpatient unit

Explanation

Valid benchmarking requires standardized outcome definitions and case-mix adjustment so that differences reflect care rather than patient characteristics or measurement variation. Raw counts and idiosyncratic definitions distort comparison.

Question 25Health information management

During a records audit, a reviewer finds that a nurse consistently documents reassessments before the intervention time recorded in the medication administration record. What is the most appropriate interpretation?

  1. The discrepancy suggests possible pre-charting and warrants review for record integrity and patient safety. Correct answer.
  2. The medication record is always wrong in such cases.
  3. The auditor should adjust the times to make the record consistent.
  4. This is expected because documentation timing is unimportant.

Explanation

Reassessment documented before the intervention indicates possible pre-charting, which compromises record integrity and may conceal missed care. The finding should trigger review, education, and corrective action rather than alteration of times.

Question 26Health information management

Which action best demonstrates that a hospice nurse understands the principle of least privilege in electronic health record access?

  1. Reviewing the records of all patients in the agency to stay informed
  2. Using a colleague's login when the nurse forgets their password
  3. Accessing only the records of patients currently assigned to the nurse's caseload Correct answer.
  4. Sharing the nurse's password with the on-call team for convenience

Explanation

Least privilege means users are granted only the minimum access necessary to perform their job. For a hospice nurse, this typically means accessing only the records of patients for whom the nurse is providing care. Broader access increases the risk of privacy breaches and is not justified by convenience.

Question 27Health information management

A hospice is designing a new paper flow sheet for nursing visits. Which element is most essential to include for legal and clinical documentation?

  1. A field for the date, time, and signature of the person completing each entry Correct answer.
  2. A section for the nurse's personal notes about family dynamics
  3. A carbon copy page for the patient to keep at home
  4. A pre-printed list of all possible diagnoses for quick circling

Explanation

Every clinical entry must be attributable, meaning it identifies who documented the care and when. Date, time, and signature provide this accountability and are required for a legally sound record. Without them, the entry cannot be reliably used for continuity, audit, or legal purposes.

Question 28Health information management

Which statement best describes the purpose of a clinical decision support (CDS) alert in a hospice electronic health record?

  1. It automatically bills for services based on documentation.
  2. It replaces the nurse's judgment with an automated order.
  3. It restricts access to the record when a patient's status changes.
  4. It provides timely information to help clinicians make informed decisions. Correct answer.

Explanation

Clinical decision support delivers patient-specific information and reminders at the point of care to enhance decision-making. It is intended to support, not replace, clinician judgment. CDS does not perform billing or access control functions.

Question 29Health information management

A hospice patient's family asks that the patient's spiritual preferences be recorded so the whole team can respect them. Where is the most appropriate place to document this information?

  1. In a personal notebook kept by the nurse
  2. In the patient's plan of care and interdisciplinary progress notes Correct answer.
  3. In the billing notes to justify chaplain services
  4. In an email to the medical director only

Explanation

Spiritual preferences are part of the holistic hospice assessment and should be documented in the plan of care and progress notes so all team members can access and honor them. This supports coordinated, patient-centered care. Personal notebooks and isolated emails do not create a shared, retrievable record.

Question 30Health information management

Which action is required when a hospice nurse receives a telephone order for a medication change?

  1. Wait until the next interdisciplinary team meeting to record it
  2. Enter the order under the prescriber's login to save time
  3. Document the order and read it back to the prescriber for verification Correct answer.
  4. Ask the pharmacist to write the order later

Explanation

Telephone orders must be documented promptly and read back to the prescriber to confirm accuracy. This closed-loop communication reduces medication errors. Delaying documentation or entering orders under another person's credentials is unsafe and noncompliant.

Question 31Health information management

Which data element is most important to capture when documenting a hospice patient's pain assessment?

  1. The time the nurse arrived at the home
  2. The nurse's opinion of the patient's family support
  3. The patient's pain intensity, location, and response to intervention Correct answer.
  4. The patient's preferred television channel

Explanation

A complete pain assessment includes intensity, location, quality, and the patient's response to interventions. These elements guide treatment and allow evaluation of effectiveness. Unrelated details do not support clinical decision-making about pain.

Question 32Health information management

A hospice agency wants to ensure that its documentation meets the requirements for Medicare hospice certification. Which source should guide the minimum content of the record?

  1. The Medicare Conditions of Participation Correct answer.
  2. The local newspaper's health section
  3. The personal preferences of the medical director
  4. The agency's marketing brochure

Explanation

The Medicare Conditions of Participation set the federal minimum standards for hospice documentation and care. Agencies must comply with these regulations to participate in Medicare. Other sources are not authoritative for regulatory compliance.

Question 33Health information management

Which practice best ensures that a hospice patient's record remains accurate when a correction is needed after the entry has been saved electronically?

  1. Deleting the original entry and re-entering the correct information
  2. Asking the IT department to alter the original entry
  3. Leaving the error and documenting the correct information in a personal note
  4. Adding an addendum that identifies the correction and retains the original entry Correct answer.

Explanation

In an electronic record, corrections should be made through an addendum that clearly identifies the change while preserving the original entry. This maintains the integrity and audit trail of the record. Deleting or altering original entries is not permitted.

Question 34Health information management

A hospice nurse is preparing to document a home visit. Which method best supports accurate and timely recording of the visit?

  1. Recording only the interventions that were successful
  2. Asking the patient's family to write the notes for the nurse
  3. Documenting at the point of care using a secure mobile device or paper form Correct answer.
  4. Waiting until the end of the week to document all visits from memory

Explanation

Point-of-care documentation improves accuracy and timeliness by capturing information when it is fresh. Secure mobile devices or paper forms protect confidentiality. Delayed or selective documentation increases the risk of errors and omissions.

Question 35Health information management

A hospice team is reviewing its health information management policies. Which action best supports compliance with the HIPAA Security Rule?

  1. Posting patient schedules on a public bulletin board
  2. Allowing all staff to use a single shared password for the EHR
  3. Storing backup tapes in an unlocked closet
  4. Conducting regular risk assessments of electronic protected health information Correct answer.

Explanation

The HIPAA Security Rule requires covered entities to conduct accurate and thorough risk assessments to identify vulnerabilities to electronic protected health information. This is a foundational step for implementing safeguards. Sharing passwords, public posting, and unsecured storage are violations.

Question 36Health information management

Which statement best describes the role of the interdisciplinary team in hospice documentation?

  1. The team may document under a single collective login to save time.
  2. Only the physician may document in the hospice record.
  3. Each discipline documents its own assessments and interventions, contributing to a shared plan of care. Correct answer.
  4. Documentation is optional for volunteers and chaplains.

Explanation

Hospice care is interdisciplinary, and each discipline contributes its own documentation to the shared plan of care. This ensures comprehensive, coordinated care. Individual logins are required for accountability, and all disciplines involved in care should document.

Question 37Health information management

A hospice patient's condition changes rapidly, and the nurse needs to communicate the change to the physician. Which documentation practice best supports continuity and safety?

  1. Sending a text message with patient identifiers to the physician's personal phone
  2. Documenting the change in the progress notes and using secure messaging or a phone call to notify the physician Correct answer.
  3. Waiting until the next scheduled visit to inform the physician
  4. Documenting the change only in the shift report given verbally

Explanation

Significant changes must be documented in the clinical record and communicated promptly through secure channels. This ensures the physician has the information needed for timely decisions and that the record reflects the communication. Verbal-only reports and unsecured texts do not meet these standards.

Question 38Health information management

Which action best reflects the principle of data minimization when documenting a hospice patient's home environment?

  1. Including the patient's financial account numbers for billing convenience
  2. Recording the full names of all visitors present during the visit
  3. Photographing the home interior for the record without consent
  4. Documenting only information relevant to the patient's care and safety Correct answer.

Explanation

Data minimization means collecting and recording only the information necessary for the purpose. In hospice documentation, this means focusing on care-relevant details. Recording unnecessary personal identifiers or financial data increases privacy risk without clinical benefit.

Question 39Health information management

A hospice agency is implementing a new electronic health record. Which strategy best supports a safe and effective transition?

  1. Turning off all system alerts to speed up documentation
  2. Providing comprehensive training and a period of parallel documentation Correct answer.
  3. Implementing the system without a downtime plan
  4. Allowing staff to skip training if they are experienced

Explanation

Safe EHR implementation requires adequate training and contingency planning. A period of parallel documentation can help maintain continuity and identify issues. Disabling alerts or skipping training increases the risk of errors and patient harm.

Question 40Health information management

Which measure best evaluates the completeness of hospice documentation for a quality improvement project?

  1. The number of staff who have personal smartphones
  2. The percentage of records containing all required assessment elements Correct answer.
  3. The average time spent by nurses typing notes
  4. The number of pages in each patient's record

Explanation

Completeness is best measured by whether required elements are present in the record. Counting pages or typing time does not reflect clinical completeness. This measure directly assesses adherence to documentation standards.

Question 41Health information management

A hospice social worker needs to share information with a community agency to coordinate services. Which action is most appropriate under privacy rules?

  1. Sharing information verbally only to avoid a paper trail
  2. Obtaining the patient's written authorization or using a permitted disclosure pathway Correct answer.
  3. Refusing all coordination to protect privacy
  4. Sharing the entire record without any restrictions

Explanation

Disclosures to external agencies generally require patient authorization or must fall under a permitted exception, such as treatment coordination. Sharing only the minimum necessary information is also required. Verbal-only sharing does not avoid privacy obligations and may be less secure.

Question 42Health information management

Which statement accurately describes the use of standardized assessment tools such as the Edmonton Symptom Assessment System (ESAS) in hospice documentation?

  1. They are only used for research and not for clinical care.
  2. They eliminate the need for patient self-report.
  3. They provide consistent, comparable symptom scores that can be tracked over time. Correct answer.
  4. They replace the need for narrative notes entirely.

Explanation

Standardized tools produce consistent scores that allow clinicians to track symptom changes and compare outcomes. They complement, but do not replace, narrative documentation and patient self-report. Their use is both clinical and research-oriented.

Question 43Health information management

A hospice nurse documents a patient's advance care planning discussion. Which element is most important to include for future decision-making?

  1. The names of all family members who were not present
  2. The nurse's personal opinion about the best choice
  3. The patient's goals, values, and specific preferences discussed Correct answer.
  4. The cost of the treatments discussed

Explanation

Advance care planning documentation should capture the patient's goals, values, and specific preferences to guide future care. This information helps the team honor the patient's wishes when the patient cannot speak for themselves. Personal opinions and unrelated details do not serve this purpose.

Question 44Health information management

Which action best protects the integrity of a hospice patient's record when multiple staff members document on the same day?

  1. Staff share a generic login to reduce password resets
  2. Each staff member uses their own unique login and documents the time of entry Correct answer.
  3. Staff document only the most significant event of the day
  4. Entries are combined into a single note signed by the team leader

Explanation

Unique logins and time-stamped entries ensure that each contribution is attributable to the correct person. This preserves the audit trail and accountability. Shared logins and combined notes obscure who did what and when.

Question 45Health information management

A hospice agency is reviewing a potential privacy breach involving a lost unencrypted laptop. Which factor is most important in determining the risk of harm to patients?

  1. The color of the laptop case
  2. The time of day the laptop was lost
  3. Whether the data on the laptop was encrypted and the sensitivity of the information Correct answer.
  4. The brand of the laptop

Explanation

Risk assessment for a breach considers the nature and sensitivity of the data and whether safeguards such as encryption were in place. Encryption can reduce the risk of harm. Physical characteristics of the device are not relevant to the risk analysis.

Question 46Health information management

Which documentation practice best supports the hospice team's ability to demonstrate compliance with the plan of care during a survey?

  1. Relying on memory to describe care during the survey interview
  2. Documenting care only when a problem occurs
  3. Using vague terms such as 'as needed' without specifics
  4. Recording the date, time, and outcome of each intervention related to the plan of care Correct answer.

Explanation

Surveyors look for evidence that planned interventions were implemented and evaluated. Documenting the date, time, and outcome of each intervention provides that evidence. Vague or event-only documentation does not demonstrate consistent care delivery.

Question 47Health information management

A hospice nurse notices that a colleague consistently documents assessments for patients they did not visit. What is the most appropriate first action?

  1. Report the concern through the agency's established compliance or quality channel Correct answer.
  2. Confront the colleague in front of the patient
  3. Ignore the behavior to avoid conflict
  4. Document the same assessments to make the record consistent

Explanation

Falsified documentation is a serious compliance and safety issue. The appropriate first step is to report the concern through the agency's established reporting channels, which may include a compliance hotline. Ignoring or replicating the behavior compounds the problem.

Question 48Health information management

A hospice program wants to use patient data for research. Which requirement is most critical before proceeding?

  1. Ensuring the data are de-identified or that appropriate consent and oversight are in place Correct answer.
  2. Publishing the data on the agency website
  3. Using only data from patients who have died
  4. Obtaining approval from the marketing department

Explanation

Research use of patient data requires either de-identification or proper consent and ethical oversight, such as an institutional review board. These safeguards protect patient privacy and comply with regulations. Marketing approval or public posting is not appropriate.

Question 49Health information management

A hospice agency discovers that a staff member accessed the record of a celebrity patient out of curiosity. Which statement best describes the appropriate response?

  1. No action is needed because the staff member has system access.
  2. The record should be deleted to avoid scrutiny.
  3. The access should be reviewed as a potential privacy violation and addressed according to policy and law. Correct answer.
  4. The staff member should be praised for being thorough.

Explanation

Accessing a record without a legitimate care or business need is a privacy violation, even if the user has system access. The agency should investigate and respond according to its policies and applicable law. Deleting records or ignoring the behavior is inappropriate.

Question 50Health information management

Which scenario most clearly demonstrates a failure of data integrity in hospice documentation?

  1. A nurse documents a patient's refusal of a treatment.
  2. A nurse documents a visit on the correct date but uses a synonym for pain.
  3. A nurse uses an approved abbreviation for a medication.
  4. A nurse copies a previous note's assessment into a new visit without verifying the patient's current condition. Correct answer.

Explanation

Data integrity requires that documentation accurately reflects the patient's current status. Copying forward previous assessments without verification creates inaccurate information and can lead to unsafe care. Using synonyms, approved abbreviations, or documenting refusals does not compromise integrity.