Topics 15 & 16: Communication; Medical Record

Which of the following is not included in the information shared between the health team members?

• What was done to the patient

• Procedures which are still to be done to the patient

• Family conflict within the patient's family

• Response of the patient to the treatment

This is a medical term which means abnormally fast or rapid heart rate.

• Tachycardia

• Hypertension

• Tachyphylaxis

• Tachypnea

The patient's medical record shall never be used as a legal evidence in court to maintain patient's confidentiality.

• True

• False

Which of the following parts of the medical record should the nurse assistant review with the nurse before providing care to a patient?

• Consultation reports

• Laboratory results

• Nursing care plan

• Medication Administration Record (MAR)

Which part of the medical record contains the patient's follow-up appointment and home medications?

• Admission Record

• Advance Directives

• Special Consents

• Discharge Summary