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 A
Explanation
A. Confidentiality: The biggest concern is maintaining patient confidentiality due to risks of unauthorized access, hacking, and breaches of protected health information (PHI).
B. Adequate forms for documentation: Computerized charting typically has structured templates, ensuring that all necessary fields are included.
C. Incorrect information: While errors can occur, computerized charting often includes safeguards like drop-down menus, alerts, and validation checks to reduce mistakes.
D. None of the answers are correct: Confidentiality is a significant concern, making option A the best answer.
Correct Answer is A
Explanation
A. The specific time of all sudden changes in the patient's condition: Timely documentation of sudden changes ensures accuracy in patient records and supports clinical decision-making.
B. The period the shift covers: While shift documentation is important, it does not replace event-specific charting.
C. Every 2 hours: Documentation frequency depends on patient status; critical changes require immediate recording, not just every 2 hours.
D. Every hour on the hour: Routine hourly documentation is unnecessary unless required by patient condition (e.g., ICU monitoring).
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