Which part of the medical record can be used as evidence in court?

the care plan

the medical orders

the entire record

nursing notes

Answer and Explanation

The Correct Answer is C

A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.

B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.

C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.

D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.

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Correct Answer is C

Explanation

A. CNA (Certified Nursing Assistant): CNAs assist with basic patient care (e.g., hygiene, vital signs) but do not perform assessments or make nursing diagnoses.

B. Technician: Technicians perform specific tasks (e.g., drawing blood, ECGs) but do not analyze patient data for diagnosis.

C. RN (Registered Nurse): The RN is responsible for analyzing and interpreting data, identifying nursing diagnoses, and developing the care plan.

D. LPN/LVN (Licensed Practical/Vocational Nurse): LPNs/LVNs can collect data but cannot make a nursing diagnosis, which is the RN’s role.

A. patient provided data B. all of the answers are correct C. observed data D. measured data

Correct Answer is A

Explanation

A. Patient provided data: Subjective data includes information the patient states, such as symptoms, pain level, or concerns.

B. All of the answers are correct: Not all answer choices describe subjective data.

C. Observed data: Observations made by the nurse (e.g., swelling, pallor) are objective, not subjective.

D. Measured data: Measurable data, such as vital signs, are objective, not subjective.

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Which part of the medical record can be used as evidence in court?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:

Correct Answer is C

Explanation

When using the SOAP method of charting, S stands for subjective data which means:

Correct Answer is A

Explanation

JCAHO regulates standards of care to:

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

Select the type of assessment which is performed continuously throughout nurse-patient contact:

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?

To what does objective data refer when assessing a patient?

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

In which step of the nursing process do nurses look at outcomes?

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as: