While documenting in a patient's chart, a nurse recognizes that
A) Documentation serves as a temporary part of the medical record.
B) Documentation is one of the least important tasks performed in nursing.
C) Documentation is the act of charting only abnormal information related to a patient.
D) Documentation is evidence of what transpired during an event requiring medical care.

Question

Quizplus · Accepted Answer

Documentation serves as evidence of what transpired during an event requiring medical care. It is an essential part of the medical record and helps to maintain accurate and up-to-date patient information. Documentation should not only include abnormal information but should also encompass all relevant patient data, including assessments, interventions, and patient responses. Nurses have an important role in documenting the care they provide to patients.

While Documenting in a Patient's Chart, a Nurse Recognizes That