Question

The nursing instructor is teaching students about legal guidelines for documentation. What guidelines for documentation should the nurse include? Select all that apply.

1. Record all facts.
2. Correct all errors promptly.
3. Chart only for yourself.
4. Document critical comments about patients.
5. Use shorthand when necessary to speed your documentation.

Answer 1

The nursing instructor should include guidelines such as recording all facts, correcting errors promptly, respecting privacy and dignity, preserving confidentiality, and seeking informed consent.

Step-by-step explanation:

When teaching students about legal guidelines for documentation, the nursing instructor should include the following guidelines:

1. Record all facts: It is important to accurately and objectively document all relevant information about a patient's condition, treatments, and outcomes.
2. Correct all errors promptly: Any errors or mistakes in documentation should be corrected as soon as possible to ensure accuracy.
3. Respect subjects' rights to privacy and dignity: Patient confidentiality should be maintained, and documentation should be done in a way that upholds the dignity and privacy of the patient.
4. Preserve confidentiality: Patient information should be kept confidential and only shared with authorized individuals.
5. Seek informed consent: When necessary, documentation should include evidence of informed consent from the patient for procedures or treatments.