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The client’s record belongs to the health care facility or provider, not to the client.The client has the right to access and request copies of their record, but they cannot take it home or remove it from the facility.

The client’s record cannot be accessed by anyone who works in the health care facility.

Only those who have a direct involvement in the client’s care or a valid reason to review the record can access it, such as nurses, physicians, therapists, quality improvement staff, etc.Accessing the record for personal or unauthorized reasons is a breach of confidentiality and can result in legal and disciplinary actions.

The proper procedure for correcting errors in documentation, such as drawing a single line through the error, writing “error” above it, initialing and dating it, and writing the correct information.

The nurse must never erase, obliterate, or use correction fluid on the record.Destroying or tampering with the record can be considered fraud or negligence and can jeopardize the nurse’s license and credibility.

The nurse does not need to ask for the client’s permission every time they need to disclose their information to someone who is part of the health care team.This would be impractical and unnecessary, as the client has already consented to share their information with those who need to know for their care.

The nurse cannot keep the client’s information anonymous when they report it to others who are involved in their care.The client’s identity is important for accurate and safe care delivery, and anonymizing their information could compromise their quality of care or lead to errors.

The nurse cannot withhold the client’s diagnosis from anyone who has a legitimate need to know, such as other health care providers, public health officials, or partner notification services.The nurse has a duty to warn those who are at risk of exposure to HIV from the client, and to comply with the legal requirements for reporting HIV cases to the state health department and CDC.

Deleting the erroneous entry may not be possible or appropriate in some systems, and it may compromise the integrity and auditability of the documentation.

Drawing a line through the erroneous entry and initialing it is a method for correcting errors in paper documentation, not computerized documentation.

Ignoring the error and hoping that no one notices it is unprofessional, unethical and potentially dangerous for the patient’s care and safety.

The client’s record is not primarily a source of evidence for legal actions, although it may be used as such in some cases.The main purpose of the record is to document the care provided to the client and the client’s response to the care.

The client’s record is not primarily a tool for quality improvement and research, although it may be used as such in some cases.The main purpose of the record is to document the care provided to the client and the client’s response to the care.

The client’s record is not primarily a means of communication among health care providers, although it may be used as such in some cases.The main purpose of the record is to document the care provided to the client and the client’s response to the care