Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

A. Incident reports must be recorded in the nurse's notes: Incident reports should not be recorded in the patient’s chart. They are used internally to improve patient safety and should be kept separate from the medical record.

B. Institutions are only reimbursed for patient care that is documented: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as documentation serves as proof that care was provided.

C. Document only when not successful: Documentation should be comprehensive, including both successful and unsuccessful interventions, to provide a full picture of patient care.

D. The patient record is a complete picture of individualized problems, treatments, and responses to treatments: A patient's medical record includes their health status, nursing interventions, and responses, making it a complete reference for continuity of care.

A. Evaluation: Evaluation is the phase where nurses assess whether patient goals and expected outcomes were met.

B. Assessment: Assessment is the first step, where data is collected to identify patient needs.

C. Implementation: Implementation involves carrying out nursing interventions, not reviewing outcomes.

D. Planning: Planning is where goals and interventions are developed, not evaluated.