A nurse is preparing to document a client's information in the electronic medical record.
Which of the following nursing statements identifies the purpose of documentation?

"Documentation enables providers to monitor the nurse.”.

"Documentation provides a communication tool for the health care team.”.

"Documentation provides information for a client audit.”.

"Documentation facilitates reimbursement from the local government.”.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While documentation can be reviewed by providers, its primary purpose is not to monitor nurses' performance. Monitoring occurs through various quality assurance processes, and documentation serves a broader range of functions beyond individual nurse oversight.

Choice B rationale

Documentation acts as a central communication hub for all members of the healthcare team, including physicians, nurses, therapists, and other specialists. It ensures continuity of care by providing a shared understanding of the client's condition, treatments, and responses, facilitating informed decision-making and collaboration.

Choice C rationale

Although documentation can be used for audits, such as financial or quality audits, this is not its primary purpose. The main goal of documentation is to provide a comprehensive record of patient care for effective communication and continuity.

Choice D rationale

While accurate documentation supports billing and reimbursement processes from various payers, including government entities, this is a secondary outcome. The primary aim of documentation is to ensure high-quality patient care through clear and comprehensive information sharing.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

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. .

A. True B. False

Correct Answer is A

Explanation

Developing a care plan is a collaborative process that ideally involves the physician, the patient, the nurse, and other members of the healthcare team. The physician's input is vital for medical diagnoses, treatment orders, and overall medical management, which are integral components of the patient's comprehensive care plan.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is preparing to document a client's information in the electronic medical record.Which of the following nursing statements identifies the purpose of documentation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is reinforcing teaching with a newly licensed nurse about accessing a client's medical records.Which of the following should the nurse include?

Correct Answer is A

Explanation

True or False: An important consideration when developing the care plan is to ensure that the physician is involved in the process.

Correct Answer is A

Explanation

The nursing process is best defined as a framework for the organization of individualized nursing care.

A nurse must give feedback to a nursing assistant that did not take vital signs.How will the nurse give feedback?

The nurse has just completed teaching the patient how to self-administer insulin injections.Which entry in the patient’s chart demonstrates that the teaching was successful?

Complete the following sentence by using the list of options.A clinical judgement about individual, family, or community responses to actual or potential health problems/life process is known as a:

Which nursing leadership approach demonstrates decentralized management?

Which chart entry represents appropriate documentation about the patient's pain assessment?

The nurse is assessing a patient with chest pain who has just come to the hospital. Which open-ended query will provide the nurse with helpful information about the patient's health status?

A nurse is preparing to document a client's information in the electronic medical record.
Which of the following nursing statements identifies the purpose of documentation?