關於病人病歷，護理師的法律職責為何？
Which of the following is the nurse's legal responsibility regarding a patient's medical records?
- AEnsuring entries are timely, accurate, and objective✓ 正解確保記錄及時、準確且客觀
- BSkipping entries during a busy shift在忙碌班次時跳過記錄
- CAllowing family members full access to the record at any time允許家屬隨時完整查閱病歷
- DCorrecting errors using correction fluid (white-out)使用修正液（白筆）更正錯誤
病歷（Medical Records）是具備法律效力的文件，在 NCLEX 考試中，紀錄必須符合「及時、準確、客觀」的原則。及時性（Timeliness）確保照護過程無斷層，準確性（Accuracy）與客觀性（Objectivity）則保護護理師免於法律訴訟，並確保醫療團隊能獲取真實的病人狀態。這題強調護理師作為專業人員的文書紀錄責任，任何塗改、延遲或主觀偏見的紀錄都會削弱法律防禦力。
Medical records are legally binding documents, and on the NCLEX, documentation must follow the principles of being timely, accurate, and objective. Timeliness ensures continuity of care, while accuracy and objectivity protect the nurse from legal action and ensure that the healthcare team has a truthful representation of the patient's status. This question emphasizes the nurse's professional responsibility for documentation; any alteration, delay, or subjective bias in the record weakens its legal defensibility.
美國醫院高度依賴電子病歷（EMR/EHR），系統會自動紀錄每個帳號的登入與修改時間（Audit trail）。在台灣常見的紙本修正習慣（如蓋章或塗改）在美國法律觀點下極具風險，美國醫院嚴格要求必須使用電子修正功能，且系統會留下修改痕跡。