The nurse makes chronological entries in a client's chart that ...

[anjilletteb]

The nurse makes chronological entries in a client's chart that include documentation about the routine care provided, assessment findings, and client problems during a 12-hour shift. Which type of charting is this nurse completing?
 
  1. Problem-oriented recording
  2. Source-oriented recording
  3. Narrative charting
  4. Plan of care

Question 2

After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why it's permissible for them to review and have access to client records in the clinical area. How should the nursing instructor respond?
 
  1. Confidentiality and privacy laws don't apply to students.
  2. Most students review so many records and charts that they could not possibly remember details from any one of them.
  3. Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence.
  4. As long as the clinical instructor is in the area, accessing client records is part of the education process.

[bubulittle310@msn.cn]

Answer to Question 1

Correct Answer: 3
Rationale 1: Problem-oriented recording is arranging the data according to the problem the client has.
Rationale 2: Source-oriented recording is arranged in separate sections for each department that contributes to the client's care. The plan of care is part of the problem-oriented medical record.
Rationale 3: Narrative charting is a traditional part of the source-oriented record. It consists of written notes that include routine care, normal findings, and client problems. There is no right or wrong order to the information, although chronological order is frequently used.
Rationale 4: The plan of care is part of the problem-oriented medical record.

Answer to Question 2

Correct Answer: 3
Rationale 1: This option is not correct; the laws do apply to students.
Rationale 2: Although this may or may not be a true statement, it is not an appropriate response to the student's question.
Rationale 3: For purposes of education and research, most agencies allow students and graduate health professionals access to client records. The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence. It is the responsibility of the student or health professional to protect the client's privacy by not using a name or any statements in the notations that would identify the client.
Rationale 4: Although this is true, the nursing instructor should not imply that the laws of confidentiality don't apply to students.

[anjilletteb]

Excellent

[diana chang]

Gracias!