A nurse is providing teaching to a newly licensed nurse about the purpose of documentation in the client’s health record.
Which of the following information should the nurse include?
A.
Grants billing to review client care provided.
B.
Allows nurses to document for other nurses on client care.
C.
Allows health care team members to document client care.
D.
Authorizes providers to co-sign on nurses’ notes.
The correct answer is:
C. Allows health care team members to document client care.
Explanation: Documentation in the client’s health record is crucial for ensuring that all members of the healthcare team can communicate and record the care provided. This documentation ensures continuity of care, allows for effective communication among healthcare professionals, and provides a legal record of the care delivered.
- A. Grants billing to review client care provided: While accurate documentation does support billing processes, this is not the primary purpose of documentation.
- B. Allows nurses to document for other nurses on client care: Nurses should only document the care they personally provide or observe, not on behalf of others.
- D. Authorizes providers to co-sign on nurses’ notes: Providers may review and co-sign notes when appropriate, but this is not the primary purpose of documentation.
Correct answer: C