When maintaining medical records for a client, the nurse knows that a medical record also serves as legally admissible evidence. What should the nurse do to ensure legally defensible charting?

Question

A) Ensure that the client's name appears on all pages.
B) Leave spaces between entries and signature.
C) Use abbreviations wherever possible.
D) Record all facts and subjective interpretations.

Answer 1

A
Feedback:
The nurse should ensure that the client's name appears on all pages to ensure legally defensible charting. The nurse should not leave spaces between entries and signature so that the document is legally acceptable. The nurse should use only abbreviations approved by the facility, and not use abbreviations wherever possible. The nurse should record all the facts but not any subjective interpretations, to ensure that the document is legal evidence.