Which part of the medical record can be used as evidence in court?

A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.: While the LPN is responsible for documenting their own care, they are not responsible for documenting care provided by unlicensed assistive personnel (UAP). Each staff member is responsible for documenting their own care.

B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.: While RNs oversee patient care, UAPs and LPNs must document the care they perform themselves.

C. All staff members should document all of the care that they have provided.: Every healthcare provider is responsible for documenting their own interventions to maintain accurate and legal records.

D. All staff should document all care they provided, but the RN (as the only independent practitioner) must sign their notes.: While RNs may sign their own documentation, they do not need to sign documentation made by LPNs or UAPs unless verification is required.

A. Wait until the end of the shift to document: Documentation should be done promptly after care is provided to ensure accuracy and completeness. Delaying documentation increases the risk of errors or omissions.

B. Cover errors with correction fluid, and write in the correct information: Errors should never be covered with correction fluid. Instead, a single line should be drawn through the mistake, followed by the correction and the nurse’s initials.

C. Use as many abbreviations as possible to save space: Only approved abbreviations should be used to avoid misinterpretation and increase clarity. Overuse of abbreviations can lead to confusion.

D. Document objective data, leaving out opinions: Documentation should be factual and objective (e.g., "Patient grimaced when moving" instead of "Patient appears to be in pain"). Subjective or opinion-based language should be avoided.

E. The date and time should be included with each entry: Every entry must have a date and time to provide an accurate timeline of care, ensuring legal protection and continuity of care.