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NCLEX · Advance Directives and Legal Rights

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

Reviewed by Jordan Morley, Editorial Lead at 247SimpleTests. Written by the 247SimpleTests Editorial Team from the official source material cited on every question.

Correct answer

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

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

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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About this topic: Advance Directives and Legal Rights

Advance directives and legal rights questions cover living wills, durable power of attorney for health care, DNR orders, client rights and the nurse's duty when a client's wishes are unclear or contested. This is one of 7 RN: Safe and Effective Care Environment questions on advance directives and legal rights, each with a full explanation on a single study page.

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