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Vascular Access Exam Prep

Category - Vascular Access Practice Test

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What is the purpose(s) of the medical record?
  1. To provide legal documentation that the patient, hospital, or health care workers can use as evidence in court proceedings.
  2. To document the chronological order of the patient’s care.
  3. To document communication between the physician and members of the healthcare team.
  4. All of the above.
Explanation
Answer: D - The medical record serves as a legal record of the patient’s illness, treatment and outcome of treatments, documents the chronological order of care received during the patient’s stay, and serves as a communication tool for physicians and the healthcare team. Because the medical record is a legal document, using white-out or erasing a mistake is not permitted. If a treatment or procedure is not documented in the medical record, it is legally considered not to have happened.
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