CNOR Operating Room Nursing

Category - Accountability

What is the most important action a nurse can do to protect themself if they become the target of legal action from a patient?
  1. Document all patient assessments, nursing diagnoses and interventions for the patient.
  2. Keep a separate notebook for the nurse’s own reference of any situations that were questionable.
  3. Have adequate professional insurance and access to a good attorney.
  4. Both A and B
Explanation
Answer: A - The most important action a nurse can do to protect themself is to document all patient assessments, nursing diagnoses and interventions for the patient. The nurse should clearly state what was done as well as what was not done, and any outcomes that resulted. Documentation protects the healthcare institution as well as the nurse, and if practices were not documented, it is assumed that they were never done.
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