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The NA/R's responsibility in record-keeping includes all of the following except:

a.) documenting what you observed, heard, and did
b.) documenting the changes in the resident's response or behavior
c.) removing pages or deleting an entry
d.) keeping the chart confidential

User Ademartini
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1 Answer

3 votes

Final answer:

The NA/R's responsibilities in record-keeping include documenting observations and changes in patient behavior, and keeping records confidential, but not removing or altering documentation.

Step-by-step explanation:

The NA/R's responsibility in record-keeping includes documenting what you observed, heard, and did as well as documenting the changes in the resident's response or behavior. Also, utmost importance is the responsibility to keep the chart confidential. However, a NA/R must never engage in the act of removing pages or deleting an entry from the health records, as this is considered unethical and may lead to legal consequences. Accurate and complete documentation is crucial as it ensures continuity of care and supports the patient's treatment plan.

The NA/R's responsibility in record-keeping includes documenting what you observed, heard, and did, documenting the changes in the resident's response or behavior, and keeping the chart confidential. However, it does not include removing pages or deleting an entry. Removing pages or deleting an entry can manipulate the record and compromise its accuracy and integrity.

User Hexfire
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