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Documentation


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You are an LPN working in a long-term care facility. You receive a call from an LPN colleague who just finished her shift. She tells you that she forgot to document an assessment and care provided for a resident. She asks you to do it for her. What are your responsibilities in this situation?

 

A: Respectfully refuse to document the care that she has provided. Leave a blank space in the resident’s chart so that she can document when she returns.

B: To ensure continuity of care, take notes about the care she provided. Then document the care provided in the resident’s chart.

C: The resident’s condition hasn’t changed, so there is no need for either you or your colleague to document the assessment or the care she provided.

D: Respectfully refuse to document the care that she has provided. Ask her to make a late entry when she returns.

Documentation is any written or electronically g​enerated information about a client that describes the care or service provided to that client. It is an integral part of nursing practice and quality care.

Documentation serves three purposes:

  1. facilitates communication;
  2. promotes safe and appropriate nursing care
  3. meets professional and legal standards.

A practice environment that has the necessary systems, supports and policies in place to enable LPNs to document appropriately, is fundamental to safe client care.​​​

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