When documenting client care, the nurse recognizes that which of the following is true about documentation of care?
a. Every nurse should anticipate having clients' records subpoenaed at some time during his or her nursing career.
b. There is a need for quicker documentation that does not reflect the nursing process.
c. The legal assumption is that care was given even if it is not documented.
d. Any method of documentation that provides comprehensive, factual information is legally unacceptable.
ANS: A
Every nurse should anticipate having clients' records subpoenaed at some time during his or her nursing career. Management literature emphasizes the need for quicker documentation that still reflects the nursing process. The legal assumption is that the care was not given unless it is documented in the client's record. Any method of documentation that provides comprehensive, factual information is legally acceptable.
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