A nurse is using a computerized documentation system in a health care facility.

Which of the following actions should the nurse take to ensure confidentiality and security?

(Select all that apply.).

Focus charting is a method of organizing health information in an individual’s record that centers on the patient’s concerns and strengths.It uses a three-column format to document the data, action and response (DAR) of each focus.

The advantages of using focus charting are:.

• It highlights the client’s concerns and strengths, which makes the care more patient-centered and holistic.

• It reduces redundancy and duplication of data, as it avoids repeating information that is already recorded in other forms or flow sheets.

• It facilitates communication among health care team members, as it promotes interdisciplinary documentation and helps organize the information in a concise and precise way.

Choice D is wrong because focus charting does not incorporate nursing diagnoses and care plans, although it is based on the nursing process.Nursing diagnoses and care plans are documented separately or as part of the action category.

Choice E is wrong because focus charting does not provide a chronological record of events, but rather organizes the data by the focus.A chronological record of events can be found in other forms of documentation, such as narrative or SOAP notes.

A. Log off the system when leaving the workstation.

This is a correct action to ensure confidentiality and security of electronic health records (EHRs).

Logging off prevents unauthorized access to client information by other users who may use the same workstation.It also protects the system from malware or cyberattacks that may compromise the data integrity or availability.

B. Shred any printouts before discarding them.

This is also a correct action to ensure confidentiality and security of EHRs.

Shredding any printouts that contain client information prevents them from being accessed by unauthorized persons who may find them in the trash or recycling bins.It also complies with the legal and ethical obligations to protect the privacy of clients.

C. Use a personal digital assistant (PDA) to access client information.

This is an incorrect action to ensure confidentiality and security of EHRs.

Using a PDA to access client information may expose the data to unauthorized access, loss, theft, or damage.

PDAs are typically not encrypted or password-protected, and may not have adequate security features or software updates to prevent cyberattacks or malware infections.PDAs may also not be compatible with the EHR system or follow the data standards and interoperability requirements.

D. Change the password at regular intervals.

This is another correct action to ensure confidentiality and security of EHRs.

Changing the password at regular intervals reduces the risk of password cracking, guessing, or phishing by unauthorized users or hackers.It also helps to maintain the accountability and authentication of authorized users who access the EHR system.

E. Report any breaches or attempted breaches to the appropriate authority.

This is also a correct action to ensure confidentiality and security of EHRs.

Reporting any breaches or attempted breaches to the appropriate authority helps to identify and mitigate the impact of any data loss, corruption, or disclosure.It also helps to comply with the legal and regulatory obligations to notify the affected clients and stakeholders, and to prevent further breaches or incidents.