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Questions and Answers

What is the primary reason for using generic names when charting medications?

To promote the use of branded medications
To reduce the risk of medication errors (correct)
To make it easier to identify the medication's trade name
To ensure compliance with pharmaceutical company guidelines

What is the recommended ink color for writing paper notes in medical records?

Red or green ink
Only black ink
Any ink color is acceptable
Blue or black ink (correct)

What should be done when amending a medical record?

Do not alter records in a way that will obliterate, obscure, or make illegible any information (correct)
Use correction fluid to conceal mistakes
Alter the original record to remove errors
Rewrite the entire record to reflect the changes

What is the primary purpose of including the date and time on each page of a paper medical record?

To provide a clear audit trail of patient care (C) Signup and view all the answers

What is the primary reason for ensuring that a patient's medical records are not lost, stolen, or damaged?

To ensure the continuity of the patient's care (D) Signup and view all the answers

What should a nurse do when writing notes on a patient's medical record?

Only write notes on what they have witnessed or assessed (C) Signup and view all the answers

What should be done when creating a retrospective note in a medical record?

Identify the note as being made retrospectively and include the date and time of the note (A) Signup and view all the answers

What is the process by which a patient can obtain a copy of their medical record from a private healthcare provider?

The patient must put their request in writing and pay the appropriate charge (D) Signup and view all the answers

In which situation can a patient be denied access to their medical record?

If reading the record would adversely affect their physical or mental health (D) Signup and view all the answers

What is the appropriate action when a patient requests to see their original medical record?

The healthcare provider should supervise the patient while they review their original medical record (B) Signup and view all the answers

What is the purpose of open disclosure?

To improve communication between healthcare providers and patients when things go wrong (A) Signup and view all the answers

Who can be authorized to access a patient's medical record?

Another person authorized by the patient (C) Signup and view all the answers

What is the primary purpose of maintaining accurate and comprehensive medical records?

To ensure effective communication among healthcare teams for continuity of care (A) Signup and view all the answers

What should medical records contain, according to best practices?

Statements of fact and clinical opinions only (A) Signup and view all the answers

What is the significance of contemporaneous records in medical practice?

They can be used as evidence in civil and criminal proceedings (B) Signup and view all the answers

What should be done when correcting errors in medical records?

Make a notation of the correction and date it (A) Signup and view all the answers

Who has access to medical records, according to standard practices?

Authorized healthcare professionals involved in the patient's care (B) Signup and view all the answers

What is the primary benefit of maintaining thorough and contemporaneous medical records?

Protecting healthcare providers from liability (A) Signup and view all the answers

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