A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical record to take, because it is her personal property. An appropriate response would be:
“The information in your medical record is confidential, and you cannot leave this facility with it."
"Because you are leaving against the medical advice of your primary care provider, you may not have the medical record."
"You are entitled to the information in your medical record, but the medical record is the property of the hospital. I will see about having a copy made for you."
"Certainly. This hospital doesn't need to keep it if you are leaving and will not be returning here."
The Correct Answer is C
A. “The information in your medical record is confidential, and you cannot leave this facility with it." While confidentiality is true, this response may seem dismissive and doesn’t address the patient’s right to access their health information.
B. "Because you are leaving against the medical advice of your primary care provider, you may not have the medical record." Leaving AMA does not negate the patient’s rights to access their medical information.
C. "You are entitled to the information in your medical record, but the medical record is the property of the hospital. I will see about having a copy made for you." This response respects the patient’s rights and explains that while the original record is hospital property, a copy can be made.
D. "Certainly. This hospital doesn't need to keep it if you are leaving and will not be returning here." This response is inaccurate as the original medical record must remain with the hospital per legal guidelines.
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View Related questions
Correct Answer is A
Explanation
A. Follows agency policy for correcting the error.
Following agency policy is the best approach, as it ensures compliance with legal and procedural standards for correcting documentation errors.
B. Whites out the wrong entry and writes the note in the chart of the correct patient. Whiting out errors is not permissible, as it can appear as an attempt to alter records and compromises the integrity of documentation.
C. Removes the page on which the error is located and documents the other correct notes. Removing pages from a medical record is improper and could be considered tampering with documentation.
D. Blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time.
Blacking out notes is not allowed, as it destroys information that should remain legible, even if it was written in error.
Correct Answer is B
Explanation
A. Saving the extra time it would take to mail the information.
The purpose of asking the patient to repeat information is not about saving time but to ensure accurate understanding.
B. Verifying that the patient understands the information.
Asking the patient to repeat the information confirms that they understood it correctly, which is essential in promoting effective communication and preventing misunderstandings.
C. Acting in a cautious way to avoid charges of negligence. While caution is involved, the primary purpose is to ensure understanding rather than legal protection.
D. Testing the patient's intelligence and memory.
This is not a test of intelligence or memory but rather a verification of understanding.