(Select All that Apply.) Information recorded in the client's medical record must be accurate and complete.
A charge nurse is reviewing legal guidelines for documentation with a newly licensed nurse.
Which of the following should the charge nurse include in the teaching? (Select 3 options)
Data contained in a client's medical record can be shared with all employees within a health care facility.
Documentation should include the nurse's interpretation of the client situation.
A medical record can be used as evidence in a court of law.
A nurse should ensure the documentation is organized and completed in a timely fashion.
Subjective opinions should be clearly identified as such in the documentation.
Correct Answer : C,D,E
Choice A rationale
Data contained within a client's medical record is not for unrestricted sharing among all employees within a healthcare facility. Access to patient information is need-to-know based and role-specific, guided by HIPAA regulations and facility policies to protect patient privacy and confidentiality.
Choice B rationale
Documentation should primarily focus on objective data, nursing interventions performed, and the client's responses. The nurse's interpretation of the client's situation should be based on factual observations and assessments, clearly documented as such, rather than subjective opinions presented as facts.
Choice C rationale
A medical record serves as a legal document that can be used as evidence in a court of law. Accurate and complete documentation provides a chronological account of the patient's care, which can be crucial in legal proceedings to demonstrate the care provided and adherence to standards.
Choice D rationale
Timely, organized, and complete documentation is essential for effective communication among healthcare team members and for providing safe and quality patient care. Accurate and up-to-date records ensure continuity of care and reflect the patient's current status and interventions.
Choice E rationale
When subjective information, such as the client's feelings or statements, is documented, it should be clearly identified as such using quotes or phrases like "client states.”. This distinguishes subjective data from objective findings and ensures clarity in the medical record. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Assessing the patient's respiratory status with auscultation of lung sounds and pulse oximetry provides immediate and critical information about the severity of the shortness of breath and the patient's oxygenation. This data is essential for guiding immediate interventions and further assessment. Normal pulse oximetry is typically 95-100%.
Choice B rationale
Telling the patient the physician will be in shortly does not address the immediate distress of acute shortness of breath and delays necessary assessment and intervention. It offers false reassurance without taking any immediate action.
Choice C rationale
While ensuring patient privacy is important, it is not the priority action in a situation of acute shortness of breath. Addressing the immediate physiological compromise takes precedence over privacy concerns at the initial moment of assessment.
Choice D rationale
Reassuring the patient that the shortness of breath will be relieved shortly, without any assessment or intervention, is inappropriate and potentially dangerous. It does not address the underlying cause and may delay necessary treatment.
Correct Answer is A
Explanation
Choice A rationale
The nursing process is a systematic, cyclical method used by nurses to identify and address patient health needs. It involves assessment, diagnosis, planning, implementation, and evaluation, providing a structured approach to problem-solving and the delivery of individualized care.
Choice B rationale
Standardized protocols offer guidelines for specific conditions but do not encompass the holistic and individualized nature of the entire nursing process. The nursing process allows for adaptation and critical thinking beyond pre-established routines to meet unique patient needs.
Choice C rationale
A legal document defining the scope of practice outlines what nurses are legally allowed to do. While the nursing process guides nursing actions, it is a framework for care delivery rather than a legal definition of professional boundaries.
Choice D rationale
While communication is integral to healthcare, the nursing process is more than just a communication tool. It is a comprehensive framework that guides all aspects of nursing care, from initial assessment to the evaluation of outcomes, involving critical thinking and clinical judgment.
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