(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
"The patient has a fractured right tibia with a cast that was applied 2 days ago" provides the Background, giving relevant history about the patient's current condition. "The nurse requests that the primary health provider examine the patient" is the Recommendation, suggesting a course of action based on the assessment. "The patient reported his pain as a 7 on a 0-10 pain scale 1 hour after he received Norco 10mg PO" describes the Situation, highlighting the current problem or change in condition. "The patient's toes are cool and pale, and the patient reports that the foot feels numb" is the Assessment, presenting the nurse's findings and interpretation of the patient's status.
Choice B rationale
This option incorrectly assigns the documentation entries to the SBAR components. The fractured tibia and cast history are background, not the immediate situation. The pain report after medication is the situation, not background. The recommendation is correctly identified, but the cool, pale, numb toes are the assessment, not the recommendation.
Choice C rationale
This option misidentifies the components. The cool, pale, numb toes are assessment findings, not the situation. The pain report after medication is the situation, not background. The fractured tibia and cast history are background, not the assessment. The request for provider examination is the recommendation.
Choice D rationale
This option incorrectly orders the SBAR components. The request for provider examination is the recommendation, not the situation. The cool, pale, numb toes are the assessment, not the background. The pain report after medication is the situation. The fractured tibia and cast history are background. .
Correct Answer is C
Explanation
Choice A rationale
Information about the family of a client in a different room (room 107) is not directly relevant to the change-of-shift report for the client in room 108. The report should focus on information pertinent to the care of the assigned client.
Choice B rationale
While the fact that a client in room 105 had a bath might be included in their specific report, it is not essential information to communicate during the change-of-shift report for the client in room 108 who has a new pain medication.
Choice C rationale
The administration of a new pain medication to the client in room 108 is crucial information for the oncoming nurse. It is essential to communicate the name of the medication, the time it was given, the dosage, the route of administration, and the client's response to the medication to ensure continuity of pain management.
Choice D rationale
The dietary preferences of a client in a different room (room 109) are not relevant to the change-of-shift report for the client in room 108. Dietary information is specific to each client and should be communicated within their individual report if pertinent to their current care.
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