Professional Responsibility State Practice Exam

What must be documented by nurses according to their accountability?

1. Only care provided to patients

2. Only care not provided to patients

3. Both care provided and reasons for care not provided

4. Only patient satisfaction surveys

The correct answer is: Both care provided and reasons for care not provided

The correct answer is that nurses must document both the care provided and the reasons for care not provided. This comprehensive documentation aligns with the broader principles of accountability within the nursing profession. Accountability entails not only demonstrating that care was delivered effectively but also ensuring transparency regarding any aspects of care that were not administered. Documenting the care provided allows for a clear record of the actions taken for a patient's health and well-being, which is crucial for ongoing care and for maintaining continuity in treatment. It is also vital for legal protection of the nurse and the healthcare institution, as thorough documentation can serve as evidence in case of disputes or investigations. Equally important is documenting the reasons for care not provided. There could be numerous valid justifications for not executing certain interventions or treatments, such as patient refusal, contraindications, lack of resources, or changes in a patient's condition. Understanding the rationale behind these decisions is essential for quality assurance, evaluating nursing practices, and ensuring patient safety. Other options fail to encompass the full scope of accountability expected from nursing professionals. Limiting documentation to only care provided overlooks critical elements of decision-making, while only documenting care not provided would ignore the valuable insights gained from the interventions that were performed. Focusing solely on patient satisfaction surveys does not address the core