A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the Intervention?

Choice A rationale

Nurses have a professional and legal obligation to maintain patient confidentiality. Accessing medical records should be limited to patients for whom the nurse is currently responsible for providing care. This ensures that patient information is viewed only when necessary for care delivery, upholding privacy and security standards.

Choice B rationale

Allowing nurses unrestricted access to any client's medical records within the healthcare facility, even without sharing, is a breach of privacy principles. Access should be role-based and justified by the need to provide care to that specific patient. Broad access increases the risk of unauthorized viewing of sensitive information.

Choice C rationale

Sharing a client's medical record information is restricted by privacy laws like HIPAA. Information can generally only be shared with individuals the patient has explicitly consented to, not automatically with immediate family members unless the patient has provided authorization. There are specific legal guidelines regarding disclosure of patient health information.

Choice D rationale

Sharing a client's medical information with other clients, even those with similar diagnoses, is a violation of patient confidentiality. Each patient's medical record is private, and discussing one patient's case with another, without explicit consent, is unethical and potentially illegal. .

Choice A rationale

While electronic medical record (EMR) systems aim to improve legibility by using standardized digital documentation, they do not entirely eliminate the need to interpret physician notes or other entries. There may still be instances where clarification or interpretation is required.

Choice B rationale

A significant benefit of implementing an EMR system is the potential to streamline documentation processes. Electronic charting can reduce the time nurses spend on manual tasks such as handwriting notes, transcribing orders, and locating paper records, thereby improving efficiency.

Choice C rationale

Password management and security protocols are often a necessary component of electronic systems to protect patient privacy and data integrity. Implementing a new EMR system may involve changes to password policies and frequency of updates, which could be a source of frustration rather than a benefit.

Choice D rationale

Access to a family member's medical record, even a child's, raises significant privacy and security concerns. Healthcare systems have strict regulations (e.g., HIPAA) to protect patient confidentiality, and nurses typically do not have unrestricted access to family members' records.