Question

When documenting information in a client's medical record, what should the nurse do consistently for each entry?

a) Use abbreviations for clarity.
b) Write personal opinions.
c) Record only the most significant findings.
d) Provide factual, objective information.

Answer 1

In medical documentation, a nurse should always provide factual, objective information, using standardized abbreviations when necessary. All relevant data must be recorded, not just the most significant findings.

Step-by-step explanation:

When documenting information in a client's medical record, the nurse should consistently provide factual, objective information for each entry. It is essential to record data accurately and without the influence of personal bias or opinion. Abbreviations are used for efficiency, but they must be standardized and commonly understood in the medical community to avoid confusion. Recording only the most significant findings is not enough; all relevant information must be documented to provide a comprehensive and accurate record. This approach ensures that the information can be reliably used by other healthcare professionals and, if necessary, for legal purposes.