Author Question: The nurse realizes that in order to share information from a client's medical record with another ... (Read 27 times)

dmcintosh · **on:** Jul 23, 2018

The nurse realizes that in order to share information from a client's medical record with another facility, the client must provide written consent. The primary reason for this requirement is to:

1. Facilitate the exchange of information between appropriate parties
2. Minimize the opportunity for this information to be assessed inappropriately
3. Ensure the client's right to have his medical information regarded as personal and confidential
4. Guarantee that the information will be shared with only those requiring it for cli-ent care purposes

Question 2

While discussing a client's medication history, the client tells the nurse that she thinks she is al-lergic to a particular type of medication. Which of the following nursing actions has priority in this situation?

1. Note the allergy on the client's Kardex.
2. Inform the provider of the client's possible allergy.
3. Review the client's medical record for confirmation of the allergy.
4. Tell the client to have all medications identified before taking them.

sylvia · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 3
Educational, military, and employment records may contain significant health care information. You need written permission from the client or guardian to access or transfer the records. Any information you obtain is confidential, and you treat it as part of the client's legal medical record. This process recognizes the client's right to confidentiality. The other three options, facilitating the exchange of information, ensuring the client's rights to have his medical information regarded as personal and confidential as well as guaranteeing the sharing of information will be only when required for client care purposes are outcomes of the process but not the primary reason for the consent.

Answer to Question 2

ANS: 3
The medical record is a valuable tool for checking the consistency and similarities of personal observations. Information such as a history of allergic reactions would be found in the medical record. Noting the allergy on the client's Kardex would be appropriate only after the allergy is confirmed; although if there was true concern, a notation of a possible allergy should be noted on the medication record. Informing the provider of the client's possible allergy would be appropri-ate after the medical record was reviewed and no mention of the allergy was confirmed or de-nied. While telling the client to have all medications identified before taking them is a safety measure appropriate for all clients, it is not the priority in this situation.