The nurse educator cautions the nurses to only record care they personally provide. When is it acceptable to document care provided by another nurse?

The nurse educator cautions the nurses to only record care they personally provide. When is it acceptable to document care provided by another nurse?

• A. When the other nurse is not registered/licensed
• B. During an emergency when more than one nurse is involved
• C. When two or more nurses care for a client, only one nurse is required to document
• D. There are no exceptions to the practice of never documenting for another

Answer: (B)

In nursing documentation, the goal is a complete, accurate record of what happened, who performed each intervention, and when it occurred. In an emergency, care often involves more than one nurse working rapidly as a team, so it’s acceptable for the documenting nurse to include care that another nurse provided to ensure the chart reflects the full sequence of events. This helps ensure patient safety and clear communication, as long as the entry accurately notes who performed the action and follows the facility’s policies for attribution and any required co-signatures or confirmations. Outside of emergencies, entries should typically reflect only what you personally observed or performed.

In nursing documentation, the goal is a complete, accurate record of what happened, who performed each intervention, and when it occurred. In an emergency, care often involves more than one nurse working rapidly as a team, so it’s acceptable for the documenting nurse to include care that another nurse provided to ensure the chart reflects the full sequence of events. This helps ensure patient safety and clear communication, as long as the entry accurately notes who performed the action and follows the facility’s policies for attribution and any required co-signatures or confirmations. Outside of emergencies, entries should typically reflect only what you personally observed or performed.