NCLEX-PN · Coordinated Care · 6 min read
Confidentiality, Documentation and Health Records
- Identify security and confidentiality safeguards required to protect client health information in oral, paper, and electronic formats.
- Apply accurate, timely, and safe documentation practices for paper and electronic health records, including error correction and medication notations.
- Differentiate the documentation responsibilities of the licensed practical/vocational nurse from the registered nurse, including the proper handling of incident reports.
Confidentiality and Safeguarding Protected Health Information
Protected health information is individually identifiable health information held or transmitted by a covered entity or its business associate in oral, paper, or electronic form. To safeguard this data, healthcare workers must access client information only as needed for authorized job duties and in accordance with HIPAA and facility policy. Healthcare team members may view health records only when access is needed for their authorized duties, which may include care coordination for clients not directly assigned to them.
Daily clinical practice requires active physical and digital safeguards. Computer screens displaying client information must be positioned away from public view to prevent unauthorized visual access. Nurses must lock a workstation when leaving it unattended and log off when finished using the electronic health record. Electronic health record login credentials and passwords must never be shared with colleagues or supervisors under any circumstances. When handling printed materials, documents containing client identifiers must be discarded in approved secure disposal containers according to facility policy, never in ordinary trash.
Verbal communication and environmental displays also present significant confidentiality risks. Nurses must avoid discussing client care in public areas such as elevators, cafeterias, hallways, and waiting rooms. When using unit whiteboards, staff must follow facility policy and use appropriate safeguards to prevent public exposure of sensitive or unnecessary client information. Outside of the healthcare facility, digital boundaries must remain absolute. Nurses must not post client photos or potentially identifiable clinical details or stories on social media. For any permitted disclosure, nurses must follow facility policy and obtain required authorization.
Common mistakes
- Documenting that an incident report was filled out or filed inside the client's legal medical record.
- Using unapproved or dangerous abbreviations, such as charting 'U' instead of 'unit', using 'QD' or 'QOD' instead of writing out 'daily' or 'every other day', writing trailing zeros (1.0 mg), or omitting leading zeros (.5 mL).
- Sharing electronic health record login credentials with colleagues, charge nurses, or supervisors, which compromises the automated audit trail.
- Failing to document communications made to the registered nurse or healthcare provider regarding abnormal data, including the time and the response received.
Key points
- Protected health information (PHI) must be safeguarded across oral, paper, and electronic formats; access is permitted only for authorized duties, which can include care coordination.
- Workstation screens must be angled away from public view, devices must be locked or logged off when unattended, and paper identifiers must be placed in approved secure disposal containers.
- Clients have a legal right to inspect, review, and request copies of their medical records, while disclosures to family require client agreement, absence of objection, or legal/professional justification.
- Suspected abuse of children, elders, or vulnerable adults must be reported promptly by the LPN/VN to the RN, as well as reported according to law and facility policy.
- Documentation must be factual, objective, nonjudgmental, chronological, and completed as soon as possible after care, never in advance.
- Paper error corrections require a single horizontal line, legible original text, 'error' or 'mistaken entry', initials, date, and time, while EHR corrections require approved addendum processes that preserve the automated audit trail.
- Incident reports are separate internal quality improvement tools; document objective event facts in the medical record, but never chart that an incident report was completed.
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