Question 15 of 40.

What is true regarding documentation of an abnormal treatment event?

A. Include all event details, notifications, interventions, and your opinion of the cause.
B. No extra documentation is required but the charge nurse and medical director must be notified.
C. Document a description of the event, including licensed nurse notification, all interventions taken, and your opinion of the cause.
D. Document a description of the event, including licensed nurse notification, all interventions taken, and patient response in the treatment record.

Accurate, timely, concise, and thorough documentation is crucial in healthcare to ensure continuity of care and legal protection. Any documentation in the electronic health record is considered a legal document, highlighting the importance of detailed record-keeping. Nurses should document a description of the event, including licensed nurse notification, all interventions taken, and patient response in the treatment record to provide a comprehensive overview for follow-up and future references.

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