A patient in the United States asks the nurse to change an incorrect allergy in the electronic health record. What is the nurse's best action?
Correct answer: C. Follow the process for requesting a record amendment
- A. Delete the entry and replace it without a note
- B. Tell the patient that records cannot be corrected
- C. Follow the process for requesting a record amendment
- D. Ask the patient's family to confirm the allergy
Explanation
Patients may request amendment of inaccurate protected health information. The nurse should use the facility's amendment process rather than deleting or secretly changing the original entry.
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About US Legal and Ethical Nursing Practice
US nursing law and ethics include state nurse practice acts, scope of practice, standards of care, negligence, malpractice, documentation, confidentiality under HIPAA and informed consent. Ethical reasoning applies autonomy, beneficence, nonmaleficence, justice and fidelity to conflicts such as refusal of treatment, advance directives, privacy breaches and mandatory reporting, which are not the same as legal liability.
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