Day 4: HIPAA, Documentation and Safety Precautions

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA is a federal law that requires Protected Health Information to be kept private and secure.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established guidelines for the use and distribution of protected health information (PHI).

Protected Health Information (PHI) includes any information about the health status, use of health care services, and payment for health services that can be linked to an individual.

This includes any patient identifiers, such as name, date of birth, medical record number, Social Security number, phone number, and address.

All treatments, assessments, test results, diagnoses, medications, and payments for services are considered PHI.

Under HIPAA, limit communication of PHI to the patient and essential clinicians and staff members.

Limit discussion of PHI among clinicians to the minimum amount of information necessary to accomplish the goal.

Furthermore, health care staff who are not directly involved in patient care are not allowed to review patient medical records unless the patient's case is being discussed during quality assurance meetings.

Patients have the right to confidentiality.

Open discussion of PHI in public areas is prohibited.

Do not disclose PHI to family members or friends unless authorized by the patient.

In some cases, PHI must be reported to regulating agencies, including cases of abuse, crime, or certain infectious diseases.

Patients also have a right to accurate medical records and can ask that any errors be corrected.


HIPAA applies to all healthcare providers

all healthcare workers must follow HIPAA regulations no matter where they are or what they are doing

penalties may be imposed for not adhering to HIPAA

A patient’s protected health information (PHI) may be shared only with those staff members are working with that resident



One of the most critical responsibilities of all health care professionals is producing proper documentation. Documentation, is a clear and accurate method of keeping track of factual information about the resident.

This includes the needs and conditions of the resident and the care that is provided by the healthcare worker.

Why document:

Documentation allows caregivers to communicate with one another

Provides a picture of the resident’s condition

Details how the resident is responding to treatment

It is a legal record of care that can be used in a court of law


If care is not documented, legally speaking the task was not performed

When should you document:

Documentation should occur as soon as possible after the car is provided to the resident

It is NEVER okay to document that care/services were provided prior to

being delivered to the resident

What should be documented:

You are responsible for documenting activities of daily living (ADLs) that

are outlined in each resident’s care plan.

Any other activities in which assistance is provided

Useful information that the family provides about the resident

Any refusal of assistance by the resident

Observations that are made regarding the resident


Accurate and complete information must be provided

Documentation must be done on time

Done in a legal manner, ensuring that all information provided is factual, without any opinions

Professional (words spelled correctly and writing is legible)


When documentation is not completed properly, there can be serious consequences.

Legal consequences, loss of job, and loss of licensure

Changes in the resident’s condition may be overlooked

Resident’s quality of care can suffer, potentially leading to injury, hospitalization, and even death

The nursing facility may be subject to survey citations which may lead to fines or other penalties. A citation is a negative mark given when a facility fails to comply with certain requirements.

Guidelines for documentation:

Document immediately after care so you don’t forget or record inaccurate information

Think before writing your reports and document as per the patient care plan

Only write facts not opinions

If you make a mistake draw one line through mistake, mark as “error” and initial


Some older individuals may not realize that some activities may be harmful to them. Communicate with residents about safety while maintaining his/her right to choices about care and activities.

The resident has the right to a safe environment. A safe environment is a place where a resident can ambulate and carry on his daily activities without obstacles or hazards that may result in injury or death. Think about safety first when you enter an area and last when you leave the area.


Decreased vision

Impaired hearing

Slower reflexes

Mental changes such as forgetfulness or confusion

Weakness due to illness, injury, or shrinking of unused muscles

The most common cause of accidents for LTC residents is falls


Recognize and report unsafe conditions that nurse aides are unable to correct.

Keep hallways and resident rooms clean, dry, and free of obstacles.

Keep equipment and supplies on one side of the hallway so that residents have an unobstructed path

Pick up any objects on the floor

Wipe spills immediately and place a wet floor sign

Keep beds in prescribed position and wheels locked

Maintain adequate lighting

Provide call signals to all residents and remind residents to call for help

Report all equipment not in proper working order and use it according to facility policy and manufacturer’s directions.

Unsafe or broken equipment should be identified and removed from service according to facility policy.



an accident or an unexpected event during the course of care that is not part of the normal routine in a healthcare facility i.e. falls, lacerations, burns


An unexpected situation which cause injury, damage of property or any other undesirable event.

The following events are considered incidents:


equipment broken or damaged


accusations against staff

blood or body fluids exposure

Your role as a healthcare worker is recognizing and reporting incidents and accidents, UNSAFE OR BROKEN EQUIPMENT should be “locked out” so that it cannot be used.

The person who discovers broken equipment should “tag” and remove the equipment as per facility policy.

Remember these guidelines for incident reporting:

explain what happened

State only facts

describe what you did in the situation


In this lesson we discussed HIPAA, Documentation, and patient safety. Take the time to review these concepts as they will serve as future reference.

Lets revise the new terms we leaned on the following quiz.

Use the link below to start your work!