Which of the following purposes for client documentation, an essential communication tool, is MOST important?

Question

a. It forms the basis for health care students learning about disease processes, medical and nursing diagnoses, and interventions.
b. It confirms the care provided to the client and outlines crucial information about the client.
c. It directs the need for research.
d. It notifies the health care provider and other health care team members about significant data obtained during nurse-client interaction.

Answer 1

B
Documentation provides written evidence of health care team members' accountability to clients, their employing institution, their professions, and society. Documentation is also a professional responsibility of each team member. It is an essential communication method to describe care provided to clients and clients' responses to care; to provide accurate data for planning care and ensuring continuity of care; to provide evidence of compliance with accreditation criteria and with professional practice standards; to provide a written legal record to protect clients, the health care facility, and the health care practitioner; and to serve as a resource for review, audit, reimbursement, education, and research.