A client is being transferred to a subacute care facility. A printed copy of the electronic medical record is sent with the client. Which documents should be included in the client's legal health record? (SELECT ALL THAT APPLY)
Event/unusual occurrence reports
Physician/nurse practitioner orders
Living will
Vital sign flow records
Proof of residence or deed to their home
Nurses assessments
Correct Answer : B,C,D,F
B. Physician and nurse practitioner orders specify the medical treatments, medications, and interventions prescribed for the client. These orders are essential for guiding care at the subacute care facility and are a critical part of the legal health record.
C. A living will, also known as an advance directive, outlines the client's preferences for medical treatment and care in the event they are unable to communicate their wishes. It is a legal document that guides decision-making regarding end-of-life care.
D. Vital sign flow records document the client's vital signs over time, including measurements such as blood pressure, heart rate, respiratory rate, and temperature. These records are essential for monitoring the client's health status and detecting trends or changes.
F. Nurses' assessments document the nursing observations, assessments, and interventions provided to the client. These assessments are crucial for ongoing nursing care and should be included in the legal health record.
A. Event or unusual occurrence reports document any incidents or deviations from the standard of care that occur during the client's hospitalization. These reports are important for quality improvement and risk management but are typically not included in the legal health record unless they directly impact the client's care.
E. Proof of residence or property ownership documents are not typically included in the legal health record. These documents are unrelated to the client's medical care and are considered personal or administrative records.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Isometric exercises typically involve pushing or pulling against a stationary object or surface. This action creates muscle tension without joint movement.
B. Using a trapeze involves lifting the body and is more related to mobility assistance rather than isometric exercise. It typically involves movement and is not considered an isometric exercise.
C. Brisk walking is a cardiovascular exercise that involves movement and does not focus on muscle contraction without movement. It improves cardiovascular fitness and endurance rather than strength through isometric contraction.
D. Active range of motion exercises involve moving joints through their full range of motion using muscle strength. This is different from isometric exercises, which involve static muscle contractions without joint movement.
Correct Answer is ["B","C","D"]
Explanation
B. Temperature can significantly affect sleep quality. Ensuring the room is kept at a comfortable temperature (not too hot or cold) can promote better sleep. This intervention is appropriate.
C. Clean and dry bed linens contribute to comfort, which is essential for promoting sleep. This intervention is appropriate.
D. Discomfort can be a major barrier to sleep. Addressing any discomfort, such as pain, anxiety, or positioning issues, can help improve the client's ability to fall and stay asleep. This intervention is appropriate.
A. Offering chocolate, which contains caffeine, close to bedtime is not recommended as caffeine can interfere with sleep. Therefore, this option is not appropriate.
E. Moving the client closer to the nursing station may increase noise and disrupt sleep, especially if there are frequent activities or conversations near the nursing station. Therefore, this option is not typically recommended unless the client requires closer monitoring due to medical reasons.
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