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","C","D","E"]
Explanation
A. Assess the language capabilities of the patient. Understanding the patient’s language capabilities is essential for effective communication and ensuring that the patient can understand the questions being asked.
B. Limit the interview to approximately 30 minutes. While it’s important to manage time, the interview should be flexible based on the patient’s needs and the complexity of the issues being discussed. Rigidly limiting the time could hinder the quality of the assessment.
C. Assess comprehension abilities of the patient. Assessing comprehension helps the nurse determine whether the patient understands the information being provided and can respond appropriately during the interview.
D. Make the patient as comfortable as possible. Creating a comfortable environment is crucial in fostering open communication and trust, which can lead to a more effective interview process.
E. Use open-ended questions. Open-ended questions encourage the patient to provide more detailed responses and express their feelings or concerns, facilitating a better understanding of their situation.
F. Obtain the patient's medical history from the primary care provider. Although obtaining a comprehensive medical history is important, the initial interview should primarily focus on gathering information directly from the patient, as they can provide valuable insights about their experiences, concerns, and context that might not be captured in previous records.
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.