Legally speaking, how would the nurse ensure that care was not negligent?
A) Verbally reporting assessments to the client's physician
B) Keeping private notes about the care given to each assigned client
C) Documenting the nursing actions in the client's record
D) Tape recording complete information for each oncoming shift
Ans: C
Legally speaking, a nursing action not documented in the client's record is a nursing action not performed. Unless the record contains written (not verbal, tape-recorded, or in private notes) documentation of care provided, the court would have no reason to accept a nurse's claim that the care was given.
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