Patient health care records are:
not used by anyone else but the direct care providers
concise, legal records of all care given and responses
owned by the patient, who has a right to see the data any time he/she wishes
confidential information and cannot be taken to court
The Correct Answer is B
A. Not used by anyone else but the direct care providers: Health records are used by multiple healthcare team members, including billing departments, insurance providers, and legal entities when required.
B. Concise, legal records of all care given and responses: Health records document all care provided, patient responses, and medical decisions. They serve as legal records in case of disputes or audits.
C. Owned by the patient, who has a right to see the data any time he/she wishes: The healthcare facility owns the records, but patients have a right to request access under HIPAA and other legal provisions.
D. Confidential information and cannot be taken to court: Health records can be subpoenaed and used in legal cases, provided they comply with confidentiality laws.
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Related Questions
Correct Answer is D
Explanation
A. Unacceptable because it is vague subjective data without supportive data: The documentation includes objective data (BP, pulse), a physician notification, an intervention (analgesic), and an outcome.
B. Good because it shows immediate response to the problem: While the response to the problem is immediate, this choice is incomplete as it does not acknowledge that the documentation reflects all aspects of assessment, intervention, and evaluation.
C. Inadequate because the time of physician notification is not listed: While including the exact time of physician notification is best practice, the record still meets documentation standards.
D. Acceptable because it includes assessment, intervention, and evaluation: The note follows the nursing process (assessment, intervention, and response/evaluation), making it acceptable documentation.
Correct Answer is B
Explanation
A. It serves as a reminder of human growth and development across the life span: Maslow’s hierarchy focuses on prioritizing needs, not general growth and development.
B. It helps in prioritizing nursing diagnoses and care: Maslow’s hierarchy is used to prioritize patient needs, ensuring physiological needs (oxygen, fluid, nutrition) come first before psychological and self-actualization needs.
C. It outlines the basic psychological needs that people have when they are hospitalized and feel anxiety: Maslow includes psychological needs, but its primary purpose is prioritizing all human needs, including physiological ones.
D. It is a framework for thinking critically: While it aids in clinical decision-making, critical thinking encompasses broader concepts beyond Maslow’s hierarchy.
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