Welcome to Module 4! This module presents guidelines for documentation—both the patient record and incident reports—and issues of confidentiality, with special emphasis on HIPAA regulations, and the challenges faced with the increased use of technology in securing and maintaining electronic health records. Additionally, this module explores professional liability insurance, focusing on issues nurses should consider and investigate when choosing a policy that will give them the best protection should a subsequent lawsuit be filed against them.

Medical records ensure that communications concerning individual patients will be available to health care providers, including the patients’ diagnoses, treatments, procedures, interventions, and response to those treatments, procedures and interventions, Communications also exist for research, quality assurance, third-party payers, and legal defense. This module outlined the reasons for written communication, explained how to document effectively, and stated general rules concerning when patient data may be disclosed to others. This module also provided an overview of professional liability insurance. Individual malpractice insurance may not prevent potential liability, but does assist the nurse if a lawsuit is filed or the nurse is named party in a lawsuit. Policies, though difficult to understand at first glance, are not really that difficult once the reader understands the various terms and phrases.

 

Discussion Question:

Please respond to ONE of the following prompts.

• How can a staff member ensure confidentiality in clinical settings? What strategies might be implemented by the nurse manager or nurse educator to promote confidentiality? What safeguards can be used to ensure confidentiality when sending medical information by fax or by e-mail?

OR

• Debate both the pros and cons of having individual professional liability insurance.

Assignment Description:

Identifying A Clinical Question

Write a 1000-1500 word essay addressing each of the following points/questions. Be sure to completely answer all the questions for each bullet point. There should be three main sections, one for each bullet below. Separate each section in your paper with a clear heading that allows your professor to know which bullet you are addressing in that section of your paper. Support your ideas with at least five (5) sources using citations in your essay. Make sure to cite using the APA writing style for the essay. The cover page and reference page in correct APA do not count towards the minimum word amount. Review the rubric criteria for this assignment.

Identify a clinical question related to your work environment, write the question in PICOT format and perform a literature search on the identified topic.

Purpose

To enable the student to identify a clinical question related to a specified area of practice and use medical and nursing databases to find research articles that will provide evidence to validate nursing interventions regarding a specific area of nursing practice.

Review the Application Case Study for Chapter 3: Finding Relevant Evidence to Answer Clinical Questions as a guide for your literature search.

Guidelines

1. Identify a clinical question related to your area of clinical practice and write the clinical foreground question in PICOT format utilizing the worksheet tool provided as a guide.
2. Describe why this is a clinical problem or an opportunity for improving health outcomes in your area of clinical practice. Perform a literature search and select five research articles on your topic utilizing the databases highlighted in Chapter 3 of the textbook (Melnyk and Finout-Overholt, 2015).
3. Identify the article that best supports nursing interventions for your topic. Explain why this article best supports your topic as you compare the article to the other four found in the literature search.