After providing medications and changing a dressing the nurse accesses the client's computerized medical record and enters the information about the care provided. Why is the nurse documenting at this time? Select all that apply
1. Evaluates individual performance
2. Helps determine the staffing needs of the care area
3. Estimates the amount of time required to provide care
4. Communicates information to other members of the team
5. Provides a permanent record of the care provided to the client
1, 2, 4, 5
Rationale 1: Documentation assists supervisory personnel toevaluate the staff's performance on a day-by-day basisfor specific clients.
Rationale 2: Documentation helps management to establish anacuity system to maintain adequate staff levels basedon client acuity.
Rationale 3: Documentation is not completed to estimate the amount of time required to provide care.
Rationale 4: Documentation communicates informationto other members of theclient's healthcare team.
Rationale 5: Documentation provides a permanent record for futurereference that may become a legal document in theevent of litigation or prosecution.
Global Rationale: Documentation assists supervisory personnel to evaluate the staff's performance on a day-by-day basis for specific clients, helps management to establish an acuity system to maintain adequate staff levels based on client acuity, communicates information to other members of the client's healthcare team, and provides a permanent record for future reference that may become a legal document in the event of litigation or prosecution.Documentation is not completed to estimate the amount of time required to provide care.
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