The primary source of assessment information is:

A. Every facility should have an approved abbreviations list. Hospitals and healthcare settings maintain a list of approved abbreviations to ensure consistency and prevent misinterpretation.

B. Creating abbreviations saves time for the person reading the chart: Unapproved abbreviations can lead to confusion and errors, potentially harming the patient.

C. Writing out questionable abbreviations could make a jury think you're hiding something: Avoiding abbreviations improves clarity, and using full words is preferred in legal documentation.

D. Abbreviating drug names and dosages helps reduce medication errors: Abbreviating drug names can cause dangerous medication errors (e.g., MS can mean morphine sulfate or magnesium sulfate). The Joint Commission prohibits certain abbreviations.

A. The insulin was administered per the nurse's testimony: In legal cases, verbal testimony alone is not sufficient without documentation.

B. None of the answers are correct: One of the answers is correct based on legal documentation principles.

C. The insulin was administered based on the witness testimony: Even though there were witnesses, medication administration must be documented for legal and clinical accountability.

D. The insulin was not administered because it was not charted: "If it wasn't documented, it wasn't done." In legal and medical practice, lack of documentation means the action cannot be verified as completed.