If an item was not charted in a health record,it is presumed that _____.
A) If it wasn't documented,it wasn't done
B) It was not necessary to document that item
C) Providers can be excused for being too busy delivering care to document
D) When an order is written,it was carried out even if not documented as such

Question

Quizplus · Accepted Answer

The principle in healthcare documentation is "if it wasn't documented, it wasn't done." This means that if something is not charted in a health record, it is presumed not to have happened. This principle ensures accuracy, accountability, and quality of patient care.

If an Item Was Not Charted in a Health Record,it