Documentation is a vital nursing role since the patient's health record:
A) should be completed accurately and in a timely manner.
B) should not be computerized (EHR) because of disclosure risks.
C) is not a legal document although they can be helpful in lawsuits.
D) cannot be used in determining billing and reimbursement issues.

Question

Quizplus · Accepted Answer

All documentation entries should be completed in a timely, accurate, and professional manner. Documentation most often is charted in the patient's EHR and standardized flow sheets according to agency policy. Patient health records are legal documents. Within the Health Insurance Portability and Accountability Act (HIPAA) guidelines, patient documentation is provided to insurance companies and others for billing and reimbursement.

Documentation Is a Vital Nursing Role Since the Patient's Health