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    Vati PN Comprehensive Predictor Proctored Exam

    A nurse is reviewing electronic health record (EHR) documentation with an assistive personnel (AP). The nurse should reinforce that the AP is permitted to document in which of the following sections of the EHR?

    Explanation & Rationale

    A. Plan of care: The plan of care is developed and updated by licensed nursing staff and other providers. Assistive personnel (AP) are not authorized to document assessments, interventions, or changes in the plan of care, as this requires professional judgment and accountability. B. Graphic record: APs can document routine, objective data such as vital signs, intake and output, and other measurable observations in the graphic or flow sheet section of the EHR. This allows for accurate tracking of trends while remaining within their scope of practice. C. Nurses' notes: Nurses’ notes require professional assessment, analysis, and evaluation of client responses to care. APs do not have the licensure to make these judgments, so they should not document in this section. D. Discharge teaching: Documentation of discharge teaching reflects the nurse’s evaluation of client understanding and education provided, which is a licensed nursing responsibility. APs can reinforce teaching but are not authorized to document it as part of the official discharge record.

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