Which part of the medical record can be used as evidence in court?
the care plan
the medical orders
the entire record
nursing notes
The Correct Answer is C
A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.
B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.
C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.
D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.
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Correct Answer is C
Explanation
A. Ensure subjective documentation: JCAHO (Joint Commission on Accreditation of Healthcare Organizations) promotes objective documentation to ensure accuracy and reliability in patient care records.
B. Make sure that all nurses use the same charting system: JCAHO does not mandate a uniform charting system, as institutions may use different electronic health record (EHR) systems.
C. Ensure quality patient care: JCAHO’s primary role is to establish and enforce standards to improve patient safety and healthcare quality.
D. Make sure insurance companies get paid correctly: JCAHO’s focus is on patient care quality, not financial reimbursement.
Correct Answer is B
Explanation
thoroughly. The patient may not have verbalized pain but could still be experiencing it.
B. The patient states, "It feels like a knife stabbing me.": This documents subjective data verbatim using the patient’s exact words, which is best practice for accuracy and clarity.
C. "Lump diminished.": This lacks specificity—the exact size, texture, or other changes should be documented using precise measurements (e.g., “Lump decreased from 3 cm to 2 cm”).
D. "Patient's condition much better today than yesterday.": This is too vague and lacks measurable indicators of improvement (e.g., vital signs, pain level, mobility).
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