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 Outcomes and Assessment Information Set (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).

Question

Quizplus · Accepted Answer

Entering patients' expressed wishes in the medical or clinical record helps ensure that the interdisciplinary team respects these wishes.According to regulations after the enactment of the Health Insurance Portability and Accountability Act (HIPAA),the patient has access to his or her own medical records and may designate others to have access.The OASIS is used to measure outcomes for quality improvement purposes; it does not contain all of the necessary information for care,such as vital signs.The MDS should be completed jointly by all members of the interdisciplinary team.

Which of the Following Is a True Statement About Documentation