A nurse is caring for a client in a healthcare facility. The nurse has to document information to maintain the health record of the client. Which description is required consistently for each charting entry?
A) Report each observation to the physician.
B) Sign the record with first initial, last name, and classification.
C) Obtain a signature from the primary care provider.
D) Provide the day of the week on the entry.
B
Feedback:
When documenting information in a health record for a client, the nurse should sign the record with his or her first initial, full name, last name, or classification. It is not necessary for the nurse to report every observation to the physician. Obtaining a signature from the physician is not absolutely essential. The nurse need not enter the day of the week for each entry, although it is mandatory to enter the date and time for every entry that the nurse makes in the record when documenting.
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