The legal aspects of documentation require which of the following?
a. factual and time-sequenced descriptive entries
b. legible printing
c. proof or evidence of any form of malpractice or negligence that occurs during a client's stay
d. lack of abbreviations
A
The health care record is a legal document that describes what happens to a client; in case of a lawsuit, the record provides proof of actions taken or not taken. Legal issues of documentation require that entries be legible, that correct spelling and grammar and authorized abbreviations be used, and that descriptive notations be factual and time-sequenced.
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