Patient health care records are:
not used by anyone else but the direct care providers
concise, legal records of all care given and responses
owned by the patient, who has a right to see the data any time he/she wishes
confidential information and cannot be taken to court
The Correct Answer is B
A. Not used by anyone else but the direct care providers: Health records are used by multiple healthcare team members, including billing departments, insurance providers, and legal entities when required.
B. Concise, legal records of all care given and responses: Health records document all care provided, patient responses, and medical decisions. They serve as legal records in case of disputes or audits.
C. Owned by the patient, who has a right to see the data any time he/she wishes: The healthcare facility owns the records, but patients have a right to request access under HIPAA and other legal provisions.
D. Confidential information and cannot be taken to court: Health records can be subpoenaed and used in legal cases, provided they comply with confidentiality laws.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The provider’s observed data: Objective data includes what the nurse or provider directly observes and measures, such as vital signs, lab results, and physical exam findings.
B. All of the answers are correct: Only option A is correct because C and D do not define objective data.
C. The patient’s perception of provided data: The patient’s perception is subjective data, not objective.
D. The patient’s request for information: A request for information is neither assessment data nor an objective finding.
Correct Answer is B
Explanation
A. Block: Block charting documents everything over a set period (e.g., entire shift), rather than only changes.
B. By exception: Charting by exception (CBE) means only documenting significant changes in condition or treatment rather than routine care.
C. Focused: Focused charting documents care related to a specific problem, not just exceptions.
D. SOAP: SOAP (Subject
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