Other than having a legal record of patient care, documentation is important as:

Question

a. evidence of physician orders
b. evidence of professional standard compliance
c. evidence of staffing patterns
d. evidence of consent for treatment

Answer 1

B
Professional responsibility and accountability are two primary reasons why nurses document. Thorough documentation provides a method of communication among health care team members, written evidence of what was done for the patient and evidence of compliance with professional practice standards. Evidence of physician orders is not seen in documentation nor is the evidence of staffing patterns or consent for treatments.