Question

The patient's history will always require documenting the _____ and some form of _____.

Option 1: Date, Medication
Option 2: Symptoms, Treatment
Option 3: Chief complaint, Allergy
Option 4: Insurance details, Payment method

Answer 1

The patient's history should always include the chief complaint and allergy information. Policies concerning health records must balance cost, quality of life, and privacy. In procedures, a nurse checks critical items to ensure patient safety.

Step-by-step explanation:

The patient's history in a healthcare setting will always require documenting the chief complaint, which is the primary reason a patient seeks medical attention, and some form of allergy information. The chief complaint provides a focal point for the initial assessment, while the allergy information is vital for ensuring the safety of the patient during treatment.

When considering health records, certain questions are essential for developing policies that address various concerns. These questions include:

1. How can the costs of treatments and diagnoses be balanced with the quality of life offered to patients?
2. What measures can be taken to enhance patient quality of life while maintaining or reducing healthcare costs?
3. How can individual privacy be protected without compromising patient safety and access to necessary medical information?

In medical procedures, it's important for a nurse to review several items aloud with the team, such as the confirmation of the procedure name, the completeness of needle, sponge, and instrument counts, appropriate labeling of any specimens, and addressing any issues with medical equipment.