Documentation and Hand-Off Communication · NCLEX Exam

When documenting a change in the patient’s status, the nurse should:

  1. Wait until the next shift to chart it for convenience.
  2. Document the change only after the physician has ordered it.
  3. Promptly record the change, action taken, and response, and notify the provider.
  4. Write 'see provider note' in the chart instead of describing it.
Show answer and explanation

Correct answer: Promptly record the change, action taken, and response, and notify the provider.

Prompt documentation of status changes, the action taken, and the patient's response is vital for accurate communication and continuity of care.

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