Question

Under the Documentation of Patient Care Standard, what must you document all instances of?

a. Only medical procedures performed.
b. Changes in the weather.
c. All patient care provided.
d. Personal opinions about the patient.

Answer 1

According to the Documentation of Patient Care Standard, it is mandatory to document all patient care provided, including medical procedures, patient assessments, and communications, with an emphasis on objectivity and factual reporting.

Step-by-step explanation:

Under the Documentation of Patient Care Standard, it is required to document all patient care provided. This includes every assessment, intervention, response to care, and any contact made with the patient or the patient's family. It's important to record all details objectively and factually, as this information is critical for the continuity of care, legal purposes, and to ensure quality and safety in patient care.

Personal opinions about the patient should not be documented as they are not relevant to patient care and can be considered unprofessional or even lead to legal issues. Weather changes are also irrelevant to patient care documentation unless they have a direct impact on the patient's condition or the care provided. Only information that pertains to medical procedures, the patient's condition, communications, and care plans should be included in the medical record.