Ethical and Legal Considerations in Documenting and Reporting
Ethical and Legal Considerations in Documenting and Reporting ( 5 Questions)
A nurse is reviewing the ethical and legal considerations of documentation and reporting.
The nurse understands that the client has the right to access their own record and to have a copy of it.
What is the rationale for this right?
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
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.
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.