Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation?
A) "The fact that the client refused the prescribed antidepressant medication was noted in his chart."
B) "I provided a detailed description of the dressing change in the client's chart in order to show it was done as prescribed."
C) "The client's wife told me he often develops a rash when he comes into contact with scented soaps,so I noted that in his chart."
D) "I had a long conversation with the client concerning his fears about his upcoming surgery and I mentioned his concerns in my nursing note."

Question

Quizplus · Accepted Answer

Common charting mistakes that can result in malpractice include the following: (1)failing to record pertinent health or drug information; (2)failing to record nursing actions; (3)failing to record that medications have been given; (4)failing to record drug reactions or changes in client's condition; (5)writing illegible or incomplete records;and (6)failing to document a discontinued medication.Detailed descriptions of procedures are not included in the nursing notes.

Which of the Following Statements Made by a Nurse Most