Adult Health Med Surg Nursing Test Banks Related

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A nurse is documenting a patient's care in the electronic health record (EHR). What principle should guide the nurse's documentation practices?

  • A. Recording only objective data to maintain accuracy
  • B. Documenting all care provided, including assessments and interventions
  • C. Avoiding documentation of errors or adverse events to prevent liability
  • D. Delaying documentation until the end of the shift to save time
Correct Answer: B

Rationale: Documenting all care provided, including assessments and interventions, is the principle that should guide the nurse's documentation practices in the electronic health record (EHR). Comprehensive and accurate documentation is essential for ensuring continuity of care, communication among healthcare team members, and legal protection. By documenting all care provided, the nurse contributes to a complete and thorough picture of the patient's condition and treatment, facilitating safe and effective patient care. This principle also aligns with professional standards and regulatory requirements, emphasizing the importance of timely and complete documentation in the EHR.