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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Use a Nursing Diagnosis from a source other than NANDA-I: NANDA-I provides standardized nursing diagnoses that ensure accurate problem identification and care planning.
B. Limit the number of interventions: Interventions should be appropriate and sufficient rather than arbitrarily limited.
C. Select interventions which will be easy to implement: Interventions should be effective and individualized, not just easy.
D. Involve the patient in the process: Patient involvement ensures better adherence, understanding, and personalized care.
Correct Answer is D
Explanation
A. Ethically can look at a friend's chart to see the diagnosis: Accessing a patient’s chart without a legitimate medical reason violates HIPAA and patient confidentiality laws.
B. Shares information from a chart to protect a friend: Confidentiality applies regardless of personal relationships. Unauthorized sharing of patient information is illegal and unethical.
C. Knows that only the Patient’s Bill of Rights advocates confidentiality: Multiple regulations, including HIPAA, protect patient confidentiality, not just the Patient’s Bill of Rights.
D. Reads charts only for professional reasons: Nurses can only access patient records when directly involved in care. Unnecessary access is a breach of confidentiality.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.