During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

A. Evaluation, planning, assessment, implementation: Evaluation is the last step, not the first.

B. Assessment, planning, implementation, evaluation
The correct order of the nursing process is:

1. Assessment – Gather data

2. Planning – Develop goals and interventions

3. Implementation – Carry out the plan

4. Evaluation – Determine effectiveness and adjust as needed

C. Implementation, assessment, planning, evaluation: Assessment must come first before implementing any plan.

D. Planning, evaluation, assessment, implementation: Planning comes after assessment, and evaluation is last, not second.

A. Incident reports must be recorded in the nurse's notes: Incident reports should not be recorded in the patient’s chart. They are used internally to improve patient safety and should be kept separate from the medical record.

B. Institutions are only reimbursed for patient care that is documented: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as documentation serves as proof that care was provided.

C. Document only when not successful: Documentation should be comprehensive, including both successful and unsuccessful interventions, to provide a full picture of patient care.

D. The patient record is a complete picture of individualized problems, treatments, and responses to treatments: A patient's medical record includes their health status, nursing interventions, and responses, making it a complete reference for continuity of care.