The nurse is caring for a patient who came to the hospital with acute shortness of breath.
What is the priority action of the nurse as the assessment process is started?

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. .

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.