Nursing 109

N109: Foundations in Nursing Practice Study Guide

Confidentiality of Health Information The patient has the right to talk privately with healthcare providers and to have their healthcare information protected. Patients also have the right to read and copy their own medical records. The patient has the right to ask that their record be changed if it is not complete, relevant, or correct. Complaints and Appeals The patient has the right to a fair, fast, and objective review of any complaint against their health plan, doctors, hospitals, or other healthcare personnel. This includes complaints about waiting times, operating hours, the actions of healthcare personnel, and the adequacyof healthcare facilities. Consumer Responsibilities In a healthcare system that protects consumer or patients’ rights, patients should expect to take on some responsibilities to get well and/or stay well (for instance, exercising and not using tobacco). Patients are expected to do things, like treat healthcare workers and other patients with respect, try to pay their medical bills, and follow the rules and benefits of their health plan coverage. Having patients involved in their care increases the chance of the best possible outcomes and helps support a high quality, cost-conscious healthcare system. 1.12 The Nursing Process Assessment A functional assessment should be done on every patient and should include a physical, social, and psychological assessment of the individual’s ability to take care of self. The assessment should include: • Health history: This history should include an assessment of sleep and dietary patterns, exercise habits, memory and communication patterns, immunization history, medication prescriptions and use, domestic abuse, medical records, and patterns of substance abuse, including tobacco, alcohol, and drugs. • Family history: This should include any factors pertinent to the individual’s health risks. This might include a family history of chronic illness, genetic diseases, or family violence. • Activities of daily living (ADLs): Can the individual bathe, dress, use the toilet, and self-feed? If not, what kind of assistance is needed? • Factors that might influence the individual’s health status include: o Health promotion activities: Exercise, dental care, and preventative healthcare o Risk behaviors o Family support mechanisms in place o Environmental factors o Physical activity level o Parental supervision of the child: Do the parents work, leaving the child alone for periods of time during the day? o Sexual behaviors o Cognitive development

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