A psychiatric–mental health nurse reading a new client's medical record from a previous admission. Which of the following should be included in the medical record?
A) Direct descriptions of the client's behaviors during hospitalization
B) Explanations of only those behaviors that demonstrate a risk for harm toward the client or others
C) All established behavior contracts and any incident reports that occur during hospitalization
D) Only behaviors that demonstrate a client's unwillingness to comply with treatments
Ans: A
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The medical record should include a comprehensive history of presenting illness, chief complaint, previous treatment approaches, diagnoses, safety risks because of specific behaviors, and direct explanation of all behaviors during hospitalization.
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