All nursing interventions that are implemented for patients must be documented or charted. The nurse knows that proper documentation of interventions leads to what positive outcome?
A) Proper documentation facilitates communication with all members of the health care team.
B) Proper documentation is only considered "legal" if documented in the paper chart.
C) Proper documentation prevents errors of omission and repetition of care.
D) Proper documentation does not directly measure goal achievement or outcomes.

Question

Quizplus · Accepted Answer

All nursing interventions that are implemented for patients must be documented or charted. In some cases, this may involve checking off an intervention in the patient's EMR designed to track the effectiveness of specific interventions. Many health care agencies have special requirements for documenting interventions such as the use of physical restraints or pain protocols. Proper documentation of interventions facilitates communication with all members of the health care team and provides an essential legal record. Accurate charting helps to alleviate omissions and repetition of care although it cannot prevent them. Documentation also allows nurses to evaluate the effectiveness of nursing interventions in meeting patient goals and outcomes, which is the final step in the nursing process.

All Nursing Interventions That Are Implemented for Patients Must Be