When coordinating the establishment of priorities of care during the planning phase of the nursing process, the framework often used is:

A. The patient record is a complete picture of individualized problems, treatments and responses to treatments
Accurate documentation gives a full and legal picture of the patient’s care and helps guide ongoing treatment.

B. Document only when not successful. All care and interventions-whether successful or not-must be documented to reflect the full scope of nursing care.

C. Institutions are only reimbursed for patient care that is documented
Reimbursement is tied to documentation; if care is not documented, it is considered not done, which can affect billing and auditing.

D. Incident reports must be recorded in the nurse's notes
Incident reports should not be referenced in patient charts to protect legal confidentiality. Documentation in the nurse’s notes should only reflect objective observations and patient status.

A. the insulin was administered based per the nurse's testimony
In legal situations, verbal testimony alone is not considered reliable unless documented. The principle is: "If it wasn’t documented, it wasn’t done."

B. the insulin was not administered because it was not charted
From a legal standpoint, lack of documentation is interpreted as the medication not being given, which may support claims of negligence or malpractice.

C. none of the answers are correct
This is incorrect because B is accurate under legal and nursing documentation standards.

D. the insulin was administered based on the witness testimony
Witnesses are supportive but do not replace legal documentation. Lack of charting still leaves the nurse liable.