Who should document care in the patient record?
The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.
The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.
All staff members should document all of the care that they have provided.
All staff should document all care they provided but the RN (as the only independent practitioner) must sign their notes.
The Correct Answer is C
A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.: While the LPN is responsible for documenting their own care, they are not responsible for documenting care provided by unlicensed assistive personnel (UAP). Each staff member is responsible for documenting their own care.
B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.: While RNs oversee patient care, UAPs and LPNs must document the care they perform themselves.
C. All staff members should document all of the care that they have provided.: Every healthcare provider is responsible for documenting their own interventions to maintain accurate and legal records.
D. All staff should document all care they provided, but the RN (as the only independent practitioner) must sign their notes.: While RNs may sign their own documentation, they do not need to sign documentation made by LPNs or UAPs unless verification is required.
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Related Questions
Correct Answer is D
Explanation
A. The patient's friends: While family and friends can provide secondary information, they are not the primary source of assessment data.
B. Past medical records: Past records can provide valuable history, but they do not replace real-time data from the patient.
C. The patient's record: The medical record is a collection of past documentation but is not a source of new assessment data.
D. The patient: The patient is the primary source of assessment data, as they provide information about their symptoms, medical history, and concerns.
Correct Answer is C
Explanation
A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.: While the LPN is responsible for documenting their own care, they are not responsible for documenting care provided by unlicensed assistive personnel (UAP). Each staff member is responsible for documenting their own care.
B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.: While RNs oversee patient care, UAPs and LPNs must document the care they perform themselves.
C. All staff members should document all of the care that they have provided.: Every healthcare provider is responsible for documenting their own interventions to maintain accurate and legal records.
D. All staff should document all care they provided, but the RN (as the only independent practitioner) must sign their notes.: While RNs may sign their own documentation, they do not need to sign documentation made by LPNs or UAPs unless verification is required.
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