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

Answer and Explanation

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.

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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

A. Assistive personnel reports the patient walks with a limp B. Patient reports pain level as 3 on a scale of 1 to 10 C. Heart rate 72 beats per minute D. Respiratory rate 22 per minute with even unlabored respirations E. Coughed up 5 mL yellow sputum F. Headache in frontal area

Correct Answer is ["C","D","E"]

Explanation

A. Assistive personnel reports the patient walks with a limp: This is secondhand information (reported by UAP), not directly observed by the nurse.

B. Patient reports pain level as 3 on a scale of 1 to 10: Pain is subjective data because it is based on the patient's self-report.

C. Heart rate 72 beats per minute: Heart rate is measured by the nurse, making it objective data.

D. Respiratory rate 22 per minute with even unlabored respirations: The nurse directly observes and measures respiratory rate, making it objective data.

E. Coughed up 5 mL yellow sputum: The nurse can observe and quantify the sputum (color and volume), making it objective data.

F. Headache in frontal area: A headache is subjective data because only the patient can describe it.

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Patient health care records are:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

Correct Answer is B

Explanation

The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

Correct Answer is ["C","D","E"]

Explanation

Who should document care in the patient record?

The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

When discovering subjective data, recognize that they relate to:

On what form/forms should the nurse chart when administering a narcotic?

The patient with a nursing diagnosis of airway clearance, ineffective, might have a desired patient outcome of:

Patient health care records are:

Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)