Question

According to the court of law, a care not documented is care not provided. What are the proper ways of documenting a patient's information? Select all that apply.

a) Record pertinent health and drug information.

b) Use a white-out correction fluid to correct wrong information.

c) Record medications that are given and any drug reaction.

d) Document discontinued medication.

e) Leave blank spaces in the nursing notes.

f) Sign with initials.

Answer 1

Proper ways of documenting a patient's information include recording pertinent health and drug information, recording medications and drug reactions, documenting discontinued medication, and signing with initials.

Step-by-step explanation:

Proper ways of documenting a patient's information include:

1. Recording pertinent health and drug information
2. Recording medications that are given and any drug reactions
3. Documenting discontinued medication
4. Signing with initials

Using white-out correction fluid to correct wrong information and leaving blank spaces in the nursing notes are not proper ways of documenting patient information because they can lead to errors or incomplete records.