A dietitian must record a patient's nutrition information in his chart, and she is waiting for the nurse to finish her notes. Which guideline must the dietitian consider when she gets the chart and starts her own documentation?
A) Review what the nurse wrote, and write the same information in her own words.
B) Leave a small amount of white space after the nurse's writing to add information later.
C) Ask the nurse to document the nutrition information as well.
D) Write a signature after the nursing information and the nutrition information.
E) Write clearly so that the nurse or anyone else reading the chart can understand the information.

Question

Quizplus · Accepted Answer

The best choice is to write clearly so that the nurse or anyone else reading the chart can understand the information. This is important for ensuring continuity of care and accurate communication between healthcare providers. While guidelines such as reviewing what the nurse wrote, leaving white space, and writing a signature are important considerations for chart documentation, they are secondary to the importance of clear and understandable writing. Asking the nurse to document the nutrition information as well may not be necessary or feasible, as it may be outside of her scope of practice or may result in duplicate documentation.

A Dietitian Must Record a Patient's Nutrition Information in His