Which actions show the nurse has an understanding of the role documentation plays in minimizing the risk of malpractice? Select all that apply
a. Including patient quotes to document subjective symptomology
b. Supporting documentation with personal opinions of the patient's behaviors
c. Being mindful to use correct spelling and punctuation in the documentation
d. Using common abbreviations in order to keep documentation brief and concise
e. Documenting the nursing evaluation of the patient's understanding of all instruc-tions
ANS: A, C, E
Adequate and legible documentation is the best means of defense against a lawsuit and the best way to validate that the nurse adhered to their scope of practice and to a safe standard of care. It is important to be specific and to document symptoms by writing in quotes how the patient expresses them. The reliability of the documentation is in question if spelling and punctuation is neglected. Documentation of all patient outcomes shows affective nursing care. Documentation should not include personal opinions or abbreviations not approved by the health care facility.
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