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 C
Explanation
A. wrings her hands and paces around the room while denying that she is upset.
This example reflects incongruence. The patient's body language (pacing, wringing hands) suggests anxiety or distress, which does not match her verbal denial of being upset.
B. states she is comfortable while she frowns, and her teeth are clenched.
This example also reflects incongruence. Her facial expression and clenched teeth contradict her statement of comfort, indicating her communication is not aligned.
C. is tearful and slow in speech when talking about her husband's death.
This example reflects congruence. The patient’s verbal expression and nonverbal cues are aligned, indicating that her communication is consistent with her emotions.
D. smiles and laughs while speaking of feeling lonely and depressed.
This example reflects incongruence. Smiling and laughing contradict the verbal expression of loneliness and depression, indicating a mismatch in her communication.
Correct Answer is D
Explanation
A. “Taking fluids poorly, but more than yesterday."
This assessment is vague (“taking fluids poorly”), lacks measurable details, and does not meet the clarity standard required in documentation.
B. "Apparently comfortable all night. Offers no complaints of pain."
“Apparently comfortable” is an assumption rather than an observable, objective statement, which could be legally questionable.
C. "Patient says she is still slightly nauseated, would like to try some toast and tea."
While this is clear, “slightly nauseated” could be more specific, and this does not objectively quantify the patient’s condition.
D. "4 cm reddened area over sacrum. Skin intact, warm, and dry."
This statement is concise, uses precise measurements, and includes objective data, meeting legal documentation guidelines.