A client is being transferred to a subacute care facility. A printed copy of the electronic medical record is sent with the client. Which documents should be included in the client's legal health record? (SELECT ALL THAT APPLY)
Event/unusual occurrence reports
Physician/nurse practitioner orders
Living will
Vital sign flow records
Proof of residence or deed to their home
Nurses assessments
Correct Answer : B,C,D,F
B. Physician and nurse practitioner orders specify the medical treatments, medications, and interventions prescribed for the client. These orders are essential for guiding care at the subacute care facility and are a critical part of the legal health record.
C. A living will, also known as an advance directive, outlines the client's preferences for medical treatment and care in the event they are unable to communicate their wishes. It is a legal document that guides decision-making regarding end-of-life care.
D. Vital sign flow records document the client's vital signs over time, including measurements such as blood pressure, heart rate, respiratory rate, and temperature. These records are essential for monitoring the client's health status and detecting trends or changes.
F. Nurses' assessments document the nursing observations, assessments, and interventions provided to the client. These assessments are crucial for ongoing nursing care and should be included in the legal health record.
A. Event or unusual occurrence reports document any incidents or deviations from the standard of care that occur during the client's hospitalization. These reports are important for quality improvement and risk management but are typically not included in the legal health record unless they directly impact the client's care.
E. Proof of residence or property ownership documents are not typically included in the legal health record. These documents are unrelated to the client's medical care and are considered personal or administrative records.
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Related Questions
Correct Answer is B
Explanation
B. Such an assessment helps in determining the level of assistance the client will need and ensures the safety of both the client and the nurse.
A. Helping the client to sit at the edge of the bed allows them to acclimate to being upright, assess their readiness to stand, and ensures their safety before attempting to walk. However, it is not the priority.
C. After assisting the client to a sitting position at the edge of the bed and assessing their readiness, the nurse can proceed to help the client into a standing position. However, it is not the priority.
D. This option may be necessary if the client requires two-person assistance due to their condition, mobility status, or safety concerns. However, asking for assistance typically comes after assessing the client's readiness and ensuring they are positioned correctly for ambulation.
Correct Answer is D
Explanation
D This action involves escalating the issue to a higher authority who can provide guidance and support. The nursing supervisor can assess the situation, provide advice on managing the critically ill client, and potentially reassign the nurse or provide additional resources.
A. This option does not address the immediate need to ensure the patient's safety and continuity of care. It's important to consider patient welfare and seek appropriate support before considering leaving the unit.
B. Discussing the client's care with another nurse could be a subsequent step, but it does not address the immediate need to ensure the nurse is qualified to provide the necessary care.
C. Proceeding without addressing the issue could jeopardize patient safety and is not ethically or professionally responsible. It's crucial to acknowledge limitations and seek appropriate assistance.
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