When the nurse charts only additional treatments done, abnormal findings, changes in patient condition, and new concerns, the system of documentation is:

Choice A rationale

Using correction tape is inappropriate as it obscures the original entry, violating the principle of maintaining a clear and accurate audit trail. This makes it impossible to determine what the original error was and who made it, which is crucial for accountability and legal purposes in healthcare documentation.

Choice B rationale

Shredding the original forms and rewriting them is unacceptable because it completely eliminates the original record. This action could be interpreted as an attempt to conceal errors or misrepresent information, which carries significant legal and ethical implications in patient care documentation.

Choice C rationale

Blacking out the error with a thick marker obscures the original information, making it impossible to review the mistake and understand the context. This method does not allow for verification of the initial entry or tracking of the correction process, which is essential for maintaining accurate medical records.

Choice D rationale

Drawing a single line through the incorrect information, making the correction clearly beside it, and then initialing and dating the change maintains the integrity of the original record while indicating who made the correction and when. This method ensures transparency and accountability in documentation, adhering to legal and professional standards for error correction in medical charts.

Choice A rationale

While the sibling may have paid for the diagnostic test, this does not grant the nurse the right to access and disclose the results. Patient privacy and confidentiality are paramount, and access to medical records is restricted to those directly involved in the patient's care. Payment for services does not override these privacy regulations.

Choice B rationale

The familial relationship between the nurse and the patient's sibling does not authorize the nurse to access the patient's medical information. Professional boundaries and ethical guidelines prevent healthcare providers from accessing records of family members unless they are directly involved in their care and have a legitimate need-to-know.

Choice C rationale

It is indeed the responsibility of the healthcare provider who ordered the tests or is managing the patient's care to disclose laboratory results and findings directly to the client. This ensures accurate interpretation and appropriate follow-up. Nurses should not bypass this process by independently accessing and sharing results with family members.

Choice D rationale

A nurse-client relationship did not exist between the nurse and the sibling in this scenario. Accessing a patient's medical record requires a legitimate professional need related to the provision of care to that specific patient. Without this established relationship, accessing the sibling's results would be a breach of confidentiality and professional ethics.