If a Client's Medical Chart Is Used in a Legal

question 32

Multiple Choice

If a client's medical chart is used in a legal proceeding,which of the following represents an example of correct documentation under the standard of practice that the jury will be looking for?

• A)Each chart entry should be signed or initialed.
• B)Administration of medications is documented before they are actually given.
• C)Nursing notes reflect facts and opinions about the client.
• D)Nursing notes are changed to reflect changes in client status.

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Definitions:

Genetic Influences

The impact of genes inherited from parents on various traits and characteristics, including physical attributes, behaviors, and susceptibility to diseases.

Schizophrenia

A mental disorder characterized by distortions in thinking, perception, emotions, language, sense of self, and behavior, often manifesting through hallucinations and delusions.

Adopted Child

A child who has been legally taken by individuals other than their biological parents to be raised as their own.

Delusions

False beliefs held despite strong evidence against them, often seen in psychiatric conditions such as schizophrenia.