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.

The nurse should use a personal password to log on and off the system and shred any unnecessary computer-generated worksheets.

These actions will help ensure confidentiality of computerized records by preventing unauthorized access and misuse of patient information.

Choice B is wrong because the nurse should not share the password with anyone, even a trusted colleague.This would violate the professional duty of maintaining a patient’s confidence and data security.

Choice C is wrong because the nurse should not leave the computer unattended while logged on.

This would create an opportunity for someone else to access or tamper with the records.

Choice E is wrong because installing a firewall on the personal computer is not enough to prevent unauthorized access.The nurse should also use encryption, antivirus software, and other security measures.

“I will only share your information with those who are directly involved in your care.”

This is because the nurse has a legal and ethical obligation to protect the client’s confidentiality and privacy, especially when dealing with sensitive information such as HIV/AIDS diagnosis.

Choice B is wrong because 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.

Choice C is wrong because 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.

Choice D is wrong because 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.

Normal ranges for HIV tests are negative or non-reactive for antibodies or antigens.A positive or reactive test indicates the presence of HIV infection and requires confirmation by a second test.

Follow the facility’s policy and procedure for correcting an entry error.This is because different computerized systems may have different methods for correcting errors, and the nurse should follow the guidelines of the specific system and facility to ensure accuracy, accountability and legal compliance.

Choice A is wrong because deleting the erroneous entry may not be possible or appropriate in some systems, and it may compromise the integrity and auditability of the documentation.

Choice B is wrong because drawing a line through the erroneous entry and initialing it is a method for correcting errors in paper documentation, not computerized documentation.

Choice D is wrong because ignoring the error and hoping that no one notices it is unprofessional, unethical and potentially dangerous for the patient’s care and safety.

The nurse should always document accurately, promptly and honestly, and report any errors or discrepancies in the documentation to the appropriate authority.

The client’s record is a reflection of the client’s health status and care.

The rationale for this right is that the client has the right to know and understand their own health condition and the care they receive from the health care providers.The client’s record is a source of information that can help the client make informed decisions about their health and well-being.

Choice A is wrong because 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.

Choice B is wrong because 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.

Choice C is wrong because 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.

Normal ranges for documentation vary depending on the type of data and the setting.

For example, vital signs, laboratory values, pain scales, and functional assessments may have different normal ranges in different contexts.Nurses should follow the policies and procedures of their organization and use standardized terminologies when documenting data.