The nurse recognizes which statement to be accurate regarding what should be documented?
A) Document facts and subjective data from the patient.
B) Document how he/she feels about the care being provided.
C) Document in a "block" fashion once per shift.
D) Double document as often as possible in order to not miss anything.

Question

Quizplus · Accepted Answer

Nursing documentation is an important part of effective communication among nurses and with other health care providers. Documentation should be factual and nonjudgmental, with proper spelling and grammar. Subjective data from the patient should be included. Events should be reported in the order they happened, and documentation should occur as soon as possible after assessment, interventions, condition changes, or evaluation. Each entry includes the date, time, and signature with credentials of the person documenting. Double documentation of data should be avoided because legal issues can arise as a result of conflicting data.

The Nurse Recognizes Which Statement to Be Accurate Regarding What