Which statement is true regarding the recording of data from the history and physical examination?
a. Use long, descriptive sentences to document findings.
b. Record the data as soon as possible after the interview and physical examination.
c. If the information is not documented, then it can be assumed that it was done as a standard of care.
d. The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient.
ANS: B
The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, then it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short, clear phrases and avoid redundant phrases and descriptions.
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