Documentation, Electronic Health Records, and Reporting 2025
A patient requests a copy of his medical record. What is the correct response by the nurse?
a. Inform him that his record is the property of the facility and cannot be accessed by anyone but staff.
b. Tell him that the Code for Nurses does not allow you to give him access to his records.
c. Acknowledge that he has the right to have a copy his records, and make arrangements per facility policy.
d. Refer his request to the hospital administrator since all such requests need to go through proper channels. -
ansAnswer: c
As part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and updated in 2009 in The
American Recovery and Reinvestment Act (ARRA), patients' rights include obtaining, viewing, or updating a
copy of their own medical records. Usually an EHR copy is sent to the patient within 30 days. Facilities can
charge the patient for the cost incurred in copying and sending medical records. Methods for implementation
vary by facility and type of medical record. The Code for Nurses does not control who has access to medical
records. Requests would go through the medical records department, or whoever is responsible for obtaining
and copying patient records.
A patient's sister comes to visit and asks to read the patient's chart. What is the best response by the nurse?
a. Settle her in a chair at the nurses' station and give her the chart.
b. Respond that the contents of a patient's chart are private and confidential.
c. Tell her she can read the chart only if the patient sits with her.
d. Distract the sister by changing the subject and then walking away. - ansAnswer: b
Without special permission from the patient, only those with a need-to-know-the-information-for-care reasons
have access to the medical record. The patient has a legal right to control access to personal information, and
the nurse should not give the sister the chart for review, even with the patient present. It is best to be honest
and explain the patient's legal rights rather than avoiding the subject.
Access to an electronic health record is controlled
a. through assignment of individual passwords and verify codes that identify the person who has the right to
enter the record.
b. by the physician.
c. by the nurse.
d. by the patient's family. - ansANS: A
, Access to an EHR is controlled through assignment of individual passwords and verification codes that identify
people who have the right to enter the record. Passwords should never be shared with anyone. Health care
information systems have the ability to track who uses the system and which records are accessed. These
organizational tools contribute to the protection of personal health information.
Charting by exception (CBE) means
a. all normal patient activities are documented.
b. standardized terminologies are not used in documentation.
c. abnormal patient responses are highlighted.
d. all patient care is considered "normal." - ansANS: C
Charting by exception (CBE) is documentation that records only abnormal or significant data. It reduces
charting time by assuming certain norms. For this type of charting, each facility must define what is normal.
Any assessment finding outside normal is charted as an exception.
Legal issues related to medical records include: (Select all that apply.)
a. The medical record is the legal documentation of care provided to a patient.
b. In the event of litigation, the medical record is often the only available evidence of an event in question.
c. Medical record documentation should be based strictly on facts, not opinions.
d. Medical record entries can be altered or erased to increase accuracy. - ansANS: A, B, C
The medical record is the legal documentation of care provided to a patient. In the event of litigation, the
medical record is often the only available evidence of the event in question. Medical record documentation
should be based on fact, not opinions. Every note in a medical record must include a date, time, and signature
with credentials. Ethical practice dictates that nurses document only interventions that are performed. Medical
record entries cannot be altered or obliterated.
Medical record documentation is important because (Select all that apply.)
a. it improves communication between providers.
b. it is the record of care provided.
c. the record becomes a legal document.
d. it is where the nurse records his or her thoughts and feelings about the patient. - ansANS: A, B, C
A patient requests a copy of his medical record. What is the correct response by the nurse?
a. Inform him that his record is the property of the facility and cannot be accessed by anyone but staff.
b. Tell him that the Code for Nurses does not allow you to give him access to his records.
c. Acknowledge that he has the right to have a copy his records, and make arrangements per facility policy.
d. Refer his request to the hospital administrator since all such requests need to go through proper channels. -
ansAnswer: c
As part of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and updated in 2009 in The
American Recovery and Reinvestment Act (ARRA), patients' rights include obtaining, viewing, or updating a
copy of their own medical records. Usually an EHR copy is sent to the patient within 30 days. Facilities can
charge the patient for the cost incurred in copying and sending medical records. Methods for implementation
vary by facility and type of medical record. The Code for Nurses does not control who has access to medical
records. Requests would go through the medical records department, or whoever is responsible for obtaining
and copying patient records.
A patient's sister comes to visit and asks to read the patient's chart. What is the best response by the nurse?
a. Settle her in a chair at the nurses' station and give her the chart.
b. Respond that the contents of a patient's chart are private and confidential.
c. Tell her she can read the chart only if the patient sits with her.
d. Distract the sister by changing the subject and then walking away. - ansAnswer: b
Without special permission from the patient, only those with a need-to-know-the-information-for-care reasons
have access to the medical record. The patient has a legal right to control access to personal information, and
the nurse should not give the sister the chart for review, even with the patient present. It is best to be honest
and explain the patient's legal rights rather than avoiding the subject.
Access to an electronic health record is controlled
a. through assignment of individual passwords and verify codes that identify the person who has the right to
enter the record.
b. by the physician.
c. by the nurse.
d. by the patient's family. - ansANS: A
, Access to an EHR is controlled through assignment of individual passwords and verification codes that identify
people who have the right to enter the record. Passwords should never be shared with anyone. Health care
information systems have the ability to track who uses the system and which records are accessed. These
organizational tools contribute to the protection of personal health information.
Charting by exception (CBE) means
a. all normal patient activities are documented.
b. standardized terminologies are not used in documentation.
c. abnormal patient responses are highlighted.
d. all patient care is considered "normal." - ansANS: C
Charting by exception (CBE) is documentation that records only abnormal or significant data. It reduces
charting time by assuming certain norms. For this type of charting, each facility must define what is normal.
Any assessment finding outside normal is charted as an exception.
Legal issues related to medical records include: (Select all that apply.)
a. The medical record is the legal documentation of care provided to a patient.
b. In the event of litigation, the medical record is often the only available evidence of an event in question.
c. Medical record documentation should be based strictly on facts, not opinions.
d. Medical record entries can be altered or erased to increase accuracy. - ansANS: A, B, C
The medical record is the legal documentation of care provided to a patient. In the event of litigation, the
medical record is often the only available evidence of the event in question. Medical record documentation
should be based on fact, not opinions. Every note in a medical record must include a date, time, and signature
with credentials. Ethical practice dictates that nurses document only interventions that are performed. Medical
record entries cannot be altered or obliterated.
Medical record documentation is important because (Select all that apply.)
a. it improves communication between providers.
b. it is the record of care provided.
c. the record becomes a legal document.
d. it is where the nurse records his or her thoughts and feelings about the patient. - ansANS: A, B, C
