Why is documenting all of the client's care at the end of the shift considered a dangerous practice?
a. It is assumed that if nothing was charted, nothing was done.
b. Other health care professionals may administer medications or provide care to the client without the necessary up-to-date information.
c. When charts are incomplete, there is a presumption that the care professional was negligent.
d. It may imply that the care of the client was inadequate.
B
Recording nursing care in a notebook or on a worksheet and then transferring the notes to a chart at the end of the shift can be a dangerous practice; other health care professionals may administer medications or provide care to the client without the much needed up-to-date information. Harm may come to the client when the client's record is inaccurate or incomplete.
Nurses' notes provide substantial evidence in a court case. It is inferred that nothing is charted because nothing was done.
When records are lost or incomplete, there is a presumption, especially in a court case, that care was negligent, resulting in the client's injuries. Incomplete or illegible records undermine the credibility of the health care professional.
Documenting all of the client's care at the end of the shift does not mean that the client did not receive adequate care.
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