Which of the following is a true statement about documentation?
a. Nurses should keep records of patients' wishes.
b. Patients do not have access to their own medical records.
c. The OASIS is a complete record of the health status of a patient.
d. The nurse is responsible for completing all of the Minimum Data Set (MDS).
A
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A Correct. Entering patients' expressed wishes in the medical or clinical record helps ensure that the interdisciplinary team respects those wishes.
B Incorrect. According to regulations following HIPAA, the patient has access to his or her own medical records and may designate others to have access.
C Incorrect. The OASIS is used to measure outcomes for quality improvement purposes. It does not contain all necessary information for care, such as vital signs.
D Incorrect. The MDS should be completed jointly by all members of the interdis-ciplinary team.
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