Nursing documentation is an important part of effective communication among nurses and with other health care providers. As such, the nurse:
a. documents facts.
b. documents how he/she feels about the care being provided.
c. documents in a "block" fashion once per shift.
d. double documents as often as possible in order to not miss anything.
ANS: A
Nursing documentation is an important part of effective communication among nurses and with other health care providers. Documentation should be factual and nonjudgmental, with proper spelling and grammar. Events should be reported in the order they happened, and documentation should occur as soon as possible after assessment, interventions, condition changes, or evaluation. Each entry includes the date, time, and signature with credentials of the person documenting. Double documentation of data should be avoided because legal issues can arise as a result of conflicting data.
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