Texas Board of Nursing (BON) Practice Exam

What information must be included in patient care documentation?

1. Only patient names and diagnoses

2. Patient assessments, care provided, medication administration, and patient responses

3. Electronic Health Records only

4. Confidential notes about the patient's family

The correct answer is: Patient assessments, care provided, medication administration, and patient responses

The correct answer emphasizes the importance of comprehensive documentation in patient care, which is essential for ensuring continuity of care, communication among healthcare providers, and legal accountability. Including patient assessments, care provided, medication administration, and patient responses paints a complete picture of the patient's status and the interventions that have occurred. Thorough documentation enables nurses and other healthcare professionals to monitor progress, identify changes in the patient’s condition, and plan future care effectively. It serves as a vital record in case of legal inquiries and quality assurance processes, ensuring that all actions taken in a patient's care are recorded and traceable. Focusing solely on patient names and diagnoses does not capture the full scope of care provided or the patient's ongoing health status, which is critical for effective management. Documenting only Electronic Health Records removes the nuance and detail that traditional documentation on care specifics provides. Lastly, keeping confidential notes about the patient's family is inappropriate in formal documentation approaches, as family details should not detract from the direct patient care information required for health records.