Documentation of type of care, time of care, and signature of the person who is documenting proves that:
a. the person who signed the documentation did all the work noted.
b. no litigation can be brought against the person who signed.
c. interventions were implemented to meet the patient's needs.
d. the patient's response to the intervention was positive.
C
This information results in recording the interventions that are implemented to meet the patient's needs. Many charting entries include doctor's visits, presence of family, or interventions by other departments. Patient response to some interventions is not always positive.
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