STTI Legal Documentation and Defenses
Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
Which documentation practice can protect a nurse in a legal case?
A. Using vague and general language
✔✔B. Documenting care thoroughly, factually, and immediately
C. Only documenting abnormal findings
D. Writing notes at the end of the shift
What is the most appropriate way to document a client’s refusal of treatment?
A. “Client said no, no reason.”
B. “Refused meds, not my problem.”
✔✔C. “Client refused medication, stating ‘I feel better and don’t need it.’”
D. “Client non-compliant again.”
Which of the following could be considered legally risky documentation?
A. “Administered 5 mg morphine IV at 1400.”
B. “Patient resting in bed.”
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, ✔✔C. “Doctor didn’t know what to do.”
D. “Client reports pain 3/10.”
Which phrase reflects **subjective** charting and could be challenged in court?
✔✔A. “Client was difficult.”
B. “Client refused lunch, stating nausea.”
C. “Client ambulated 10 feet with assistance.”
D. “Client has a red, swollen left ankle.”
What is the legal risk of not documenting patient education?
A. The patient might forget instructions
B. The physician might not know
✔✔C. There is no legal proof that teaching occurred
D. The chart might look incomplete
What is a legal benefit of using standard documentation formats?
✔✔A. Promotes consistency and reduces missed data
B. It looks more professional
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Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
Which documentation practice can protect a nurse in a legal case?
A. Using vague and general language
✔✔B. Documenting care thoroughly, factually, and immediately
C. Only documenting abnormal findings
D. Writing notes at the end of the shift
What is the most appropriate way to document a client’s refusal of treatment?
A. “Client said no, no reason.”
B. “Refused meds, not my problem.”
✔✔C. “Client refused medication, stating ‘I feel better and don’t need it.’”
D. “Client non-compliant again.”
Which of the following could be considered legally risky documentation?
A. “Administered 5 mg morphine IV at 1400.”
B. “Patient resting in bed.”
1
, ✔✔C. “Doctor didn’t know what to do.”
D. “Client reports pain 3/10.”
Which phrase reflects **subjective** charting and could be challenged in court?
✔✔A. “Client was difficult.”
B. “Client refused lunch, stating nausea.”
C. “Client ambulated 10 feet with assistance.”
D. “Client has a red, swollen left ankle.”
What is the legal risk of not documenting patient education?
A. The patient might forget instructions
B. The physician might not know
✔✔C. There is no legal proof that teaching occurred
D. The chart might look incomplete
What is a legal benefit of using standard documentation formats?
✔✔A. Promotes consistency and reduces missed data
B. It looks more professional
2
