The nurse is documenting positioning for the client. Which piece of documentation is not required?
1. Number of personnel required for turning and positioning
2. Client's ability to assist with positioning
3. Any signs of pressure areas or contractures
4. Instructions provided to unlicensed assistive personnel (UAP)
Correct Answer: 4
The nurse would not document instructions provided to staff in the client's medical record. However, the nurse would document the number of personnel required for turning and positioning the client, to provide for continuity of care. The client's ability to assist with positioning is important documentation to track the client's progress. Pressure areas or contractures are important information to document.
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