Which type of documentation are nurses responsible for maintaining?

Nurses are primarily responsible for maintaining the medication administration record (MAR) because this document is essential for tracking and managing a patient’s medication regimen. The MAR provides a detailed account of medications administered, including dosages, timing, and routes of administration. This responsibility is integral to ensuring patient safety and effective medication management.

In the context of direct patient care, nurses play a vital role in medication management, requiring accurate and timely documentation to prevent errors and ensure that patients receive the appropriate treatments. The information captured in the MAR is crucial for communication among healthcare team members, allowing for continuity of care and informing future decisions regarding patient treatment.

Other types of documentation, while important, fall outside the primary responsibilities of nurses. For example, radiology reports and operative reports are typically generated by specialized practitioners such as radiologists and surgeons, respectively, and are managed within the healthcare system by those professionals rather than nurses. Therapy assessments may be conducted by therapists or specialists, with the content supported by nurses but not solely maintained by them. Therefore, the MAR stands out as the documentation type that aligns closely with the nursing profession's specific duties.