Question

Asuka is caring for a patient recovering from surgery and has been advised to increase the patient’s medication. Where should she document this?

A.

in the patient’s medical record


B.

in the PBR


C.

in her own private notes


D.

on a shared whiteboard in the hospital lobby

Answer 1

Asuka should document the increase in medication in the patient’s medical record (option A). The patient’s medical record is a legal document that contains all relevant information about the patient’s health status, medical history, and treatment plan. It is important to keep accurate and up-to-date documentation of any changes made to the patient’s treatment plan to ensure continuity of care, facilitate communication between healthcare professionals, and to meet legal and regulatory requirements. Documentation in a PBR (option B) or in her own private notes (option C) is not sufficient as these documents are not accessible to all members of the healthcare team and may not be considered legal records. Documenting the increase in medication on a shared whiteboard in the hospital lobby (option D) is not an appropriate or secure method of documentation and can compromise patient confidentiality.

Step-by-step explanation:

please follow me for more if you need any help