N400, PrepU for Ch 16 (Documentation)

The health care provider approaches the nurse caring for the client in room 25 and states, "The client is a friend of mine. What treatment is being given?" What response by the nurse is most appropriate? a) Inform the health care provider that client permission is needed to release any information. b) Open the health care record for the doctor to review the treatment ordered. c) Inform the health care provider of a busy schedule preventing answering any questions at this time. d) Tell the health care provider to contact the provider caring for the client to obtain any information.

a) Inform the health care provider that client permission is needed to release any information. Explanation: Even though the health care provider may be a friend of the client, the privacy laws must be followed. The client must give permission to release any information. Opening the medical record or telling the health care provider to contact another provider for information would violate client privacy. Telling the doctor the nurse is busy does not address the issue of client privacy.

The nurse hears an unlicensed assitive personel (UAP) discussing a client's allergic reaction to a medication with another UAP in the cafeteria. What is the priority nursing action? a) Remind the UAP about the client's right to privacy. b) Document the UAP's conversation. c) Report the UAP to the nurse manager. d) Notify the client relations department about the breech of privacy.

a) Remind the UAP about the client's right to privacy. Explanation: The nurse should first remind the UAP about the client's right to privacy. All other actions are appropriate, but do not immediate protect the client's privacy.

Which principle should guide the nurse's documentation of entries on the client's health care record? a) Correcting fluid is used rather than erasing errors. b) Nurses should not refer to the names of physicians. c) Precise measurements should be used rather than approximations. d) Documentation does not include photographs.

c) Precise measurements should be used rather than approximations. Explanation: Precise measurements and times must be used whenever possible. It is appropriate to use the names of physicians, and photographs can constitute documentation. Handwritten entries should be struck through with a single line, not covered with correcting fluid or erased.

The nursing student is discussing the benefits of electronic charting with a precepting nurse who is frustrated with computerized documentation. Which statement by the student requires intervention from the nursing instructor? a) "You can make extra money with overtime pay with end-of-shift charting." b) "You don't have to worry about trying to read poor handwriting." c) "The computer reminds the nurse to enter information and inhibits omissions." d) "You save time because you don't have to look for the physical chart."

a) "You can make extra money with overtime pay with end-of-shift charting." Explanation: There are many benefits to electronic charting, though there may be some learning curves involved in knowing how to use electronic formats. It is incorrect to suggest that overtime pay can be earned with end-of-shift charting. Therefore, this statement requires intervention. The other statements are appropriate.

According to the Candian Nurses Association (CNA), what is the primary source of evidence to measure performance outcomes against standards of care? a) Documentation b) Clinical judgment c) Accreditation d) Psychomotor skills

a) Documentation Explanation: Documentation is the primary source of evidence use to measure performance outcomes, according to the ANA. Accreditation, psychomotor skills, and clinical judgment are incorrect.

The nurse in making an entry on the client's charted "Medicated with meperidine 50 mg at midnight." How would the nurse document the entry using military time? a) 2401 b) 0000 c) 1201 d) 1200

b) 0000 Explanation: 0000 is the military time for midnight and is correct. The other military times are incorrect, since 2401 is 1 minute passed midnight, 1200 is noon, and 1201 is 1 minute passed noon.

An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. What response by the nurse is most appropriate? a) Explain the reason why information cannot be disclosed. b) Verify the insurance coverage before giving information. c) Mediate a meeting between the parent and client. d) Refer the parent to the physician providing care.

a) Explain the reason why information cannot be disclosed. Explanation: The nurse needs to explain the reason why information cannot be released to the parents. Providing insurance coverage does not negate the privacy laws. Referring the parent to the physician is inappropriate since the physician cannot release the information either. Mediating a meeting between the parent and client would only be appropriate if the client requested the meeting.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: a) limiting abbreviations to those approved for use by the institution. b) using only abbreviations whose meaning is self-evident to an educated health professional. c) ensuring that abbreviations are understandable to clients who may seek access to their health records. d) using only those abbreviations that are defined in full at another location in the client's chart.

a) limiting abbreviations to those approved for use by the institution. Explanation: In addition to avoiding abbreviations that are prohibited by The Joint Commission, it is important to limit the use of abbreviations to those that are recognized and approved for use by the institution where care is being provided. The criterion of being "self-evident" is not an accurate or consistent basis for choosing abbreviations. Approved abbreviations need not be defined in full within the chart, and the client's potential understanding of abbreviations is not taken into account during the process of documentation. As a result, clients need the assistance of a member of the care team when reviewing their chart.

Which nurse to provider interaction correctly utilizes the SBAR format for improved communication? a) "I am calling about Mr. Jones in room 212. His blood glucose is 250 mg/dL (13.875 mmol/L), and I think that is high." b) "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." c) "I am calling about the patient in room 212. He has new onset diabetes mellitus, and I wondered if you would like to adjust the sliding scale of insulin." d) "I am calling about Mr. Jones who has diabetes mellitus. His blood sugar seems high, and I think he needs more insulin."

b) "I am calling about Mr. Jones. He has new onset diabetes mellitus. His blood glucose is 250 mg/dL (13.875 mmol/L), and I wondered if you would like to adjust the sliding scale insulin." Explanation: SBAR refers to: S (Situation): What is the situation you are calling about; B (Background): Pertinent background information related to the situation; A (Assessment): What is your assessment of the situation; R (Recommendation): Explain what is needed or wanted. These elements must be included in the communication for the SBAR format to be effective. When some of this information is omitted, it does not demonstrate proper use of the SBAR format.

A nurse is requesting to receive the change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate? a) "It will let me see everything that has been done and things that need to be done." b) "It will allow for us to see the client and possibly increase client participation in care." c) "It makes our client feel like we care, especially if we start the day off with a clean room." d) "It will give me a better sense of what my workload will be today."

b) "It will allow for us to see the client and possibly increase client participation in care." Explanation: Beside reports are driven to increase client safety and stimulate participation in care. While the nurse can see what has not been done, it is not the main reason for bedside reporting. A clean room is not a part of bedside reporting. Bedside reporting should be client-focused, not nurse-focused.

The nurse manager is developing an educational seminar on how to protect clients' identities. Which information should be included in the teaching? (Select all that apply) a) Conversations about clients must take place in private places where they cannot be overheard. b) Computer screens must be oriented towards the public view. c) Light boxes for examining X-rays with the client's name must be in private areas. d) Documentation must be kept of personnel who have accessed a client's record. e) The names of the clients on charts should be visible to the public.

b) Conversations about clients must take place in private places where they cannot be overheard. c) Light boxes for examining X-rays with the client's name must be in private areas. d) Documentation must be kept of personnel who have accessed a client's record. Explanation: Documentation must be kept of personnel who have accessed a client's record, light boxes for examining X-rays with the client's name must be in private areas, and conversations about clients must take place in private places where they cannot be overheard are useful strategies to limit casual access to the identity of clients and health informatics. Computer screens that are oriented toward the public view and visibly displaying clients' names on charts are incorrect, as these are breaches of patient confidentiality

A nursing student is making notes that include client data on a clipboard. Which statement by the nursing instructor is most appropriate? a) "Be sure to write down specific information for your clinical paperwork." b) "Be sure to put the client's name and room number on all paperwork." c) "Clipboards with client data should not leave the unit." d) "You can get an electronic print out of client lab data to take with you."

c) "Clipboards with client data should not leave the unit." Explanation: HIPAA has created several changes that protect client confidentiality and affect the workplace. One such change is that the names of clients on charts can no longer be visible to the public, and clipboards must obscure identifiable names of clients and private information about them. Therefore, writing down clinical information, taking the data off the unit, and including client identifiers are inappropriate statements.

A nursing student has established a strong therapeutic rapport with a patient who was admitted to the hospital with a perforated appendix. The patient is similar in age to the student and is interested in a career in nursing. Before being discharged, the patient asks if she can add the student as a contact on a social networking site in order to ask her more questions about nursing. How should the student respond to the patient's request? a) Offer to answer the patient's questions by e-mail rather than through contact on a social networking site. b) Explain that nurses are not permitted to have social contact with patients but offer to answer questions before the patient is discharged. c) Explain why nursing ethics does not allow online contact between nurses and patients. d) Explain why she cannot fulfill the patient's request but offer to meet her in person to answer questions about nursing school.

b) Explain that nurses are not permitted to have social contact with patients but offer to answer questions before the patient is discharged. Explanation: Nurses are not permitted to have social contact with patients, whether by electronic or face-to-face means. However, there is no reason not to answer the patient's queries about nursing school and the nursing profession prior to the patient's discharge.

The nurse is documenting a variance that has occurred during the shift. This report will be used for quality improvement to identify high-risk patterns and, potentially, to initiate in-service programs. This is an example of which type of report? a) Transfer report b) Incident report c) Nurse's shift report d) Telemedicine report

b) Incident report Explanation: An incident report, also termed a variance report or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in (or has the potential to result in) harm to a client, employee, or visitor. These reports are used for quality improvement and not for disciplinary action. They are a means of identifying risks and high-risk patterns as well as initiating in-service programs to prevent future problems. A nurse's shift report is given by a primary nurse to the nurse replacing her, or by the charge nurse to the nurse who assumes responsibility for continuing client care. A transfer report is a summary of a client's condition and care when transferring clients from one unit or institution to another. A telemedicine report can link health care professionals immediately and enable nurses to receive and give critical information about clients in a timely fashion.

The nurse is sharing information about a client at change of shift. The nurse is performing what nursing action? a) Dialogue b) Reporting c) Verification d) Documentation

b) Reporting Explanation: Reporting takes place when two or more people communicate information about client care, either face to face, or by recording, computer charting, or telephone. Dialogue is two-way communication, which is not always the case for reporting

A nursing student is beginning a clinical placement at a health-care facility that uses the Nursing Minimum Data Set (NMDS). The NMDS will assist the student in which of the following aspects of care? a) Diagnosing the patient health problems b) Standardizing the collection and recording of data c) Comparing the patient's health to that of similar individuals d) Eliciting the patient's and family's input into care

b) Standardizing the collection and recording of data Explanation: The NMDS was nursing's initial attempt to standardize the collection of essential nursing data and is comparable to traditional forms of documentation. The NMDS does not exist to elicit patient input, to diagnose health problems, or to compare the patient with other individuals.

Which finding from a nursing audit reflects high standards for client safety and institutional health care? a) The nurse fails to identify the nursing diagnoses or clients' needs. b) The nurse documents clients' responses to nursing interventions. c) The nurse records inappropriate nursing interventions. d) The nurse fails to adequately complete data on clients' health history and discharge planning.

b) The nurse documents clients' responses to nursing interventions. Explanation: Documenting clients' responses to nursing interventions is correct, as this shows evidence of quality care as stipulated by the Joint Commission. Inappropriate nursing interventions, unidentifiable nursing diagnoses or clients' needs, and missing data on clients' health history and discharge planning are incorrect, as these do not reflect high standards for client safety and institutional health care, which could cause the agency to lose accreditation.

Which entries should the nurse include in charting? Select all that apply. a) I feel something is going on she is not telling me. b) The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. c) The incision is oozing a small amount of red blood. d) The client was overheard telling his family about more bleeding than he has reported to his physician. e) The client's pupils are dilated.

b) The unlicensed assistive personnel (UAP) reports the client's breath smelled of alcohol. c) The incision is oozing a small amount of red blood. d) The client was overheard telling his family about more bleeding than he has reported to his physician. e) The client's pupils are dilated. Explanation: Entries must be accurate. Nurses must chart only observations that they have seen, heard, smelled, or felt. An observation made by another health professional must be clearly identified as such.

Which statements accurately describe best practices for charting? Select all that apply. a) Always use complete sentences. b) Use only approved abbreviations. c) Always use the client's name and words referring to the client in each entry. d) Use long narratives to be sure the documentation is understood. e) Use partial sentences and phrases.

b) Use only approved abbreviations. e) Use partial sentences and phrases. Explanation: Good charting is concise and brief. In narratives, use partial sentences and phrases; drop the client's name and terms, referring to the client. Use abbreviations but only those that are commonly accepted and approved by the facility.

A nurse on a night shift entered an older adult client's room during a scheduled check and discovered the client on the floor beside the bed, the result of falling when trying to ambulate to the washroom. After assessing the client and assisting into the bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? a) gauging the nurse's professional performance over time b) identifying risks and ensuring future safety for clients c) protecting the nurse and the hospital from litigation d) following up the incident with other members of the care team

b) identifying risks and ensuring future safety for clients Explanation: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team.

Which documentation tool will the nurse use to record the client's vital signs every 4 hours? a) Medication record b) Acuity charting forms c) A flow sheet d) 24-hour fluid balance record

c) A flow sheet Explanation: A flow sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to the client's condition and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs.

A client accuses a nurse of negligence when he trips when ambulating for the first time since hip replacement surgery. Which action is the best defense against allegations of negligence? a) Notifying the nursing team of the client's condition b) Keeping an accurate medication record c) Accurately documenting client care on the client record d) Documenting client data on the flow sheet

c) Accurately documenting client care on the client record Explanation: The client record is the only permanent legal document that details the nurse's interactions with the client and is the nurse's best defense if a client or client surrogate alleges nursing negligence. As the question is written, the only answer that addresses the situation is accurate documentation of the event in the client's record. Notifying the nursing team of the client's condition is important, but not the correct answer for the question. Client data should be correctly documented on the flow sheet, but this is not the correct answer in this case. The medication record should be accurate, but this is not the best answer.

A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? a) Finding the emergency medical technicians that transported the family members about the injuries b) Accessing the electronic health record of the family member to find out extent of injury c) Calling the client information desk to find out the room number of the family member d) Asking the emergency department nurse for information on the family member

c) Calling the client information desk to find out the room number of the family member Explanation: Getting information from other health care providers violates client privacy. Health care workers must follow the same guidelines to accessing health information on people not assigned to their care.

An EHR system is being introduced into a large health-care organization and nurses are being careful to ensure that the system adheres to the Canadian Nurses Association (CNA) Code of Ethics. What action is most likely to achieve this goal? a) Educating patients and families in the operation of the system b) Obtaining informed consent before documenting each intervention or assessment finding c) Ensuring that privacy and confidentiality are thoroughly protected by the system d) Validating documentation entries with the patient

c) Ensuring that privacy and confidentiality are thoroughly protected by the system Explanation: Privacy and confidentiality are the major ethical issues involved in the use of EHRs. Informed consent is necessary but not before each and every intervention or documentation entry. It is not always necessary or practical to validate documentation with the patient, and it is not normally necessary to educate patients and families on the specific operation of the EHR system.

The nurses at a health care facility were informed of the change to organize the clients' records into problem-oriented records. Which explanation could assist the nurses in determining the advantage of using problem-oriented records? a) Problem-oriented recording is difficult to demonstrate a unified approach for resolving the clients' problem among caregivers. b) Problem-oriented recording gives the clients the right to withhold the release of their information to anyone. c) Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. d) Problem-oriented recording has numerous locations for information where each member of the multidisciplinary team makes entry about their own specific activities in relation to the client's care.

c) Problem-oriented recording emphasizes goal-directed care to promote the recording of pertinent data that will facilitate communication among health care providers. Explanation: Emphasizing goal-directed care to promote the recording of pertinent data that will facilitate communication among healthcare providers is an advantage of problem-oriented recording and is therefore correct. Giving the clients the right to withhold the release of their information to anyone is beneficial disclosure, and is not an advantage for problem-oriented recording. Demonstrating a unified approach for resolving the clients' problem among caregivers and having numerous locations for information where each member of the multidisciplinary team makes entries about their own specific activities in relation to the client's care are examples of source-oriented recording.

A nurse is maintaining a problem-oriented medical record for a client. Which component of the record describes the client's responses to what has been done and revisions to the initial plan? a) Problem list b) Plan of care c) Progress notes d) Data base

c) Progress notes Explanation: In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.

The nursing is caring for a client who requests to see a copy of his or her health care records. What action by the nurse is most appropriate? a) Access the health care record at the bedside and show the client how to navigate the electronic health record. b) Explain that only a paper copy of the health care record can be viewed by the client. c) Review the hospital's process for allowing clients to view their health care records. d) Discuss how the hospital can be fined for allowing clients to view their health care records.

c) Review the hospital's process for allowing clients to view their health care records. Explanation: The nurse needs to be aware of the policies regarding clients reviewing health care records. Teaching the client how to navigate the health care records is not appropriate. Hospitals can be fined for not allowing clients to view their health care records. There is no regulation requiring the clients to view a paper copy of the records.

The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? a) The plan includes interventions, evaluation, and response. b) Objective data is what the client states about the problem. c) Subjective data should be included when documenting. d) Abnormal laboratory values are common items that are documented.

c) Subjective data should be included when documenting. Explanation: Subjective data should be included when using the SOAP format for documentation. Objective data is what the nurse observes. The plan part of a SOAP note includes interventions, but not evaluation and response. Assessment of the SOAP note is more about the health care providers' judgment of the situation, and abnormal lab values would be included in objective data.

Which strategy could be implemented by the nurse in ensuring the protection of electronic data at healthcare agencies? a) The nurse gives unlimited access to the multidisciplinary team so that personnel from various departments could retrieve the data. b) The nurses are expected to change their access number and password less frequently. c) The nurse locks out client information, except to those who have been authorized through appropriate security measures. d) The nurse is being asked to remove screen saver for data that have been displayed for prolong periods.

c) The nurse locks out client information, except to those who have been authorized through appropriate security measures. Explanation: Locking out client information except to those who have been authorized through fingerprints or voice activation is correct, since this enhances confidentiality and protects electronic data in health agencies. Less frequently changing access numbers and passwords is incorrect, since this could allow staff who have left the agency to compromise the system. Removing automatic save and screen saver for data that have been displayed for prolong periods is incorrect, since this practice could allow unscrupulous individuals onto the system. Providing unlimited data access to the multidisciplinary team so personnel from various departments could retrieve the data is incorrect, because this could allow all staff access to information that does not impact their jobs.

When charting the assessment of a client, the nurse writes, "Client is depressed." This documentation is an example of: a) factual statement. b) important information. c) interpretation of data. d) relevant data.

c) interpretation of data. Explanation: It is always best to describe behavior rather than to interpret behavior. Recording the client's behavior factually allows other professionals to explore causes of the behavior with the client. Stating that "Client is depressed" is an interpretation of the client's behavior and not a factual statement.

A client was admitted to the emergency department with a confirmed diagnosis of tuberculosis. To whom should the nurse report this diagnosis? a) Health Canada b) client's family c) public health department d) client's employer

c) public health department Explanation: Notifying the public health department of communicable disease is considered an exemption for beneficial disclosure. Health Canada is not involved in individual incidences of illness. The client's employer is not privy to the information for confidentiality reasons.

A community health nurse provides information to a client with newly diagnosed multiple sclerosis about a support group at the local hospital for clients with the disease, and their families. Providing this information is an example of: a) consultation. b) conferring. c) referral. d) reporting.

c) referral. Explanation: Referring is the process of sending or guiding the client to another source for assistance. Consultation is the process of inviting another professional to evaluate the client and make recommendations about treatment. Conferring is to consult with someone to exchange ideas or seek information, advice, or instructions. Reporting is the oral, written, or computer-based communication of client data to others.

The nurse is preparing a SOAP note. Which assessment findings are consistent with objective client data? a) concerned with feeling tired b) describes wound as itchy c) urine output 100 ml d) pain rating of 4 on a scale of 0-10

c) urine output 100 ml Explanation: Objective data is collected by the nurse, such as the measurable urine output. Subjective data, such as feeling pain, itchiness, or fatigue, is reported by the client.

The nurse is using the SOAP format of charting during a home visit to a new mother. Which of the following data should the nurse document under the "P" domain of this format? a) "Client states that she is having difficulty getting her infant to latch." b) "Client's breasts appear engorged." c) "Client states that she has diffuse breast tenderness." d) "Client referred to the health unit's drop-in breastfeeding clinic."

d) "Client referred to the health unit's drop-in breastfeeding clinic." Explanation: SOAP charting culminates with a plan—in this case, a referral to a breastfeeding clinic. Subjective findings (e.g., complaints of tenderness and difficulty latching) and objective assessment findings (visible breast engorgement) precede this plan.

A nursing student has searched the literature from information on the care of venous ulcers. After finding an article that specifically addresses this clinical topic, the student should prioritize what question? a) "Who funded this research study?" b) "How will this information affect my patient?" c) "Is it feasible to implement these findings?" d) "How credible is this information?"

d) "How credible is this information?" Explanation: Each of the listed questions is a valid and important consideration. However, the credibility of information is a priority; if the information is not credible, each of the other listed questions is irrelevant.

The health care provider tells the client, "You are experiencing a MI," and leaves the room. The client asks the nurse what a MI stands for. What response by the nurse is most accurate? a) "Mitochondria inflammation." b) Myopia instability." c) "Muscle infection." d) "Myocardial infarction."

d) "Myocardial infarction." Explanation: The common abbreviation for myocardial infarction is MI.

The parent of a 33-year-old client who is admitted to the hospital for drug and alcohol withdrawal asks about the client's condition and treatment plan. What action by the nurse is most appropriate? a) Provide the information to the parent. b) Take the parent to the client's room and have the client give the requested information. c) Explain the reasons for the hospitalization, but give no further information. d) Ask the client if information can be given to the parent.

d) Ask the client if information can be given to the parent. Explanation: No information should be provided by the nurse without permission from the client. Taking the parents to the client's room to get information from the client may violate the client's privacy.

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception (CBE). What is a benefit of this method of documentation? a) It records progress under problems, intervention, and evaluation. b) It documents assessments on separate forms. c) It provides and refers to a client's problem by a number. d) It provides quick access to abnormal findings.

d) It provides quick access to abnormal findings. Explanation: Charting by exception (CBE) provides quick access to abnormal findings as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

The nurse is finding it difficult to plan and implement care for a client and decides to have a nursing care conference. What action would the nurse take to facilitate this process? a) The nurse, along with other nurses, visits clients with similar problems individually at each client's bedside in order to plan nursing care. b) The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. c) The nurse sends or directs someone to take action in a specific nursing care problem. d) The nurse meets with nurses or other health care professionals to discuss some aspect of client care.

d) The nurse meets with nurses or other health care professionals to discuss some aspect of client care. Explanation: A nursing care conference is a meeting of nurses to discuss some aspect of a client's care.

Which action by the nurse could result in the accrediting body withdrawing the health agency's accreditation? a) identifying nursing diagnoses or clients' needs b) documenting client's health history and discharge planning c) recording appropriate nursing interventions d) omitting client's response to nursing interventions

d) omitting client's response to nursing interventions Explanation: Omitting the client's response to nursing interventions is correct because it does not fit the criteria for legally defensible charting. Recording appropriate nursing interventions, identifying nursing diagnoses or client needs, and documenting clients' health history and discharge planning are all criteria for legally defensible charting and would demonstrate evidence of quality care.