When documenting information in a client's medical record, which of the following should the nurse do consistently for each entry?
A) Report each observation to the physician.
B) Sign each entry by name and title.
C) Obtain a signature from the physician.
D) Provide the day of the week on the entry.
B
Feedback:
When documenting information in a client's medical record, the nurse should sign each entry by name and title. 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, but the nurse must enter the date and time for each entry.
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