What key guidelines are generally accepted for documentation of nursing care? Select all that apply.
A) Document what should be done.
B) Documentation should be specific.
C) Use direct quotes in documentation whenever possible.
D) Documentation should be completed promptly.
E) Document what you see.

Question

Quizplus · Accepted Answer

Documentation should be specific to ensure clarity and accuracy. Using direct quotes when possible adds precision to the documentation. Prompt completion of documentation ensures that details are recorded while still fresh, enhancing accuracy. Documenting what is directly observed rather than what should be done or inferred ensures objectivity and reliability in the record.

What Key Guidelines Are Generally Accepted for Documentation of Nursing