A nurse administers a medication for pain but forgets to document it in the client's medical record. Legally, what does this mean?
A) Nothing, the nurse's honesty will not be questioned.
B) The nurse can add the documentation after the client goes home.
C) The physician will verify that the nurse carried out the order.
D) In the eyes of the law, if it is not documented, it was not done.

Question

Quizplus · Accepted Answer

In the eyes of the law, if it is not documented, it was not done. This is a common legal principle in healthcare called "if it's not documented, it didn't happen." It is important for nurses to document all medication administration accurately and promptly to ensure patient safety and legal protection. The nurse should not add the documentation after the fact, as this is considered falsifying medical records. The physician may verify that the nurse carried out the order, but this does not excuse the lack of documentation.

A Nurse Administers a Medication for Pain but Forgets to Document