Question.1471 - Week 3: Discussion - Introduction to the Patient Record - Part 2 1212 unread replies.1818 replies. Introduction to the Patient Record - Topic Description A physician needs to make an amendment to a patient's record and asks their nurse to make the amendment. Can the nurse make this amendment on their behalf? Why or why not? Discussion Guidelines: Each week you will have a topic to answer and then respond to at least two classmates. This means, that if you follow the minimum posting requirements you will have one main substantive answer in each thread, and one response to at least two classmates. Altogether 3 posts, 2 of which will be on different days of the week. Be sure to check in if you have questions. Grading rubric for discussion posting per thread: Main post - 10 points (high quality) Response posts - 10 points (total of all responses) Post by Wednesday - 5 points This topic was locked Apr 13 at 4:59pm.
Answer Below:
In my opinion, the nurse cannot make the amendment to a patient’s record on behalf of the physician due to several factors. Firstly, the primary responsibility is of the physician to ensure that the information contained in the patient’ record is correct and complete. The physician will be held accountable if any kind of misleading information is found in the patient's record. Making amendments to a patient’s record does not fall under the scope of authority of the nurse. A patient’s record is considered to be a useful legal document and making any kind of changes in these records does not fall under their domain. If an amendment is made to the medical records of the patient, it is considered to be a case of unauthorized access given to the personnel by the physician. The physician is the one who prepares the medical records of the patient and he or she is the only one who can make the required amendments to the patient's and no other person has got the authority to make changes in it which also includes the patient himself. The nurse can help the physician in order to make the necessary changes with the appropriate documentation, but the final check needs to be done by the physician only. The patient’s record contains sensitive and confidential information about the patient, if any other person gets access to this data, this is considered to be the breach of confidentiality. It is important to consider that a physician receives proper training to maintain the records of the patient and the nurses do not have the adequate knowledge to make the amendments in the patient’s records. Therefore, it can be concluded that the nurses should not ne allowed to make amendment to a patients record, and the physician should be solely held accountable for the patient’s record. References Frequently asked questions - Medical records. (n.d.). UCLA Health. https://www.uclahealth.org/patient-resources/support-information/medical-records/frequently-asked-questionsMore Articles From Strategic Management
.ico)
.ico)
.ico)
.ico)
