The nurse is conducting a health history on a client who is being admitted to a medical-surgical unit for the treatment of chronic pain
The client is concerned about privacy and asks why it is necessary for the nurse to ask for private information and then document it in the medical record. Which response by the nurse is most appropriate?
A) "You will be able to read the record and review your care."
B) "Documentation decreases the likelihood that you will have to repeat this information to others who will care for you."
C) "Your family can review the record and ensure that care is appropriate."
D) "A record ensures there are no breaches of confidentiality."
Answer: B
The client's record serves as a vehicle by which different health professionals who interact with a client communicate with one another. This prevents fragmentation, repetition, and delays in client care, and relieves the client from having to repeat information to each provider offering care. The client can read the record, but that is not a reason to keep one. The client's family does not have access to the record. Record keeping does not prevent breaches of confidentiality.
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