If a client's medical chart is used in a legal proceeding, which of the following represents an example of correct documentation under the standard of practice that the jury will be looking for?
a. Each chart entry should be signed or initialed.
b. Administration of medications is documented before they are actually given.
c. Nursing notes reflect facts and opinions about the client.
d. Nursing notes are changed to reflect changes in client status.
A
Correct documentation under the standard of practice should include objective and accurate information to describe what is seen and done, and that each chart entry should be signed or initialed. When a chart ends up in court, this is the standard that the jury applies when determining what happened and who is at fault.
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