The client’s record is a private and confidential document that is protected by law. This means that only authorized personnel who have a legitimate need to access the record can do so, and that the record cannot be disclosed to anyone without the client’s consent or a court order. The client’s record is also a legal document that serves as evidence of the care provided and the client’s condition and response. Therefore, it must be accurate, complete, objective, timely, and legible.

Choice A is wrong because 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.

Choice B is wrong because 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.

Choice D is wrong because the client’s record cannot be altered or destroyed by the nurse if it contains errors.

The nurse must follow 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.

Normal ranges for documentation vary depending on the type of information recorded, such as vital signs, laboratory values, assessment findings, etc.

The nurse should follow the standards and policies of their facility and professional organizations when documenting.