NCLEX · General

A client asks to see their own medical record. What is the nurse's best response?

Correct answer

Recognize the client's right to access their medical record, and follow facility policy/procedure to facilitate the request

  1. A Refuse, as records belong only to the facility
  2. B Recognize the client's right to access their medical record, and follow facility policy/procedure to facilitate the request
  3. C Tell the client records are confidential from them
  4. D Give a copy without any documentation

Why this is the answer

Clients have a RIGHT to ACCESS their own medical records (under HIPAA and patient rights). The nurse should recognize this right and FOLLOW FACILITY POLICY/PROCEDURE to facilitate the request (which may involve a formal request, a designated process, and the provider/medical records department). NCLEX safe care/legal-ethical. The record's physical/electronic form belongs to the facility, but the client has the right to access and obtain a copy of the information. The nurse facilitates, doesn't refuse. HIPAA protects health information privacy AND grants patients rights to access their own information. Knowing clients have the right to access their records (and the nurse facilitates per policy) is a tested patient-rights concept.
Source: NCLEX Safe Care — Patient Right to Records

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