A client slipped and fell in the bathroom. When filling out an ...

[savannahhooper]

A client slipped and fell in the bathroom. When filling out an incident report, the nurse should
 
  a. record complete, pertinent health information.
  b. write about the incident report in the client record.
  c. store the incident report in the client record.
  d. make untimely entries.

Question 2

When documenting client care, the nurse recognizes that which of the following is true about documentation of care?
 
  a. Every nurse should anticipate having clients' records subpoenaed at some time during his or her nursing career.
  b. There is a need for quicker documentation that does not reflect the nursing process.
  c. The legal assumption is that care was given even if it is not documented.
  d. Any method of documentation that provides comprehensive, factual information is legally unacceptable.

[adf223]

Answer to Question 1

ANS: A
A mistake to avoid is failing to record complete, pertinent health information. Other mistakes to avoid include making untimely entries and writing about mistakes or incident reports in the client record. Incident reports are stored separately.

Answer to Question 2

ANS: A
Every nurse should anticipate having clients' records subpoenaed at some time during his or her nursing career. Management literature emphasizes the need for quicker documentation that still reflects the nursing process. The legal assumption is that the care was not given unless it is documented in the client's record. Any method of documentation that provides comprehensive, factual information is legally acceptable.

[savannahhooper]

Thanks for the timely response, appreciate it

[helenmarkerine]

Excellent