Legally, if a treatment was performed but not charted in the patient’s record, it was:

• A. Not done
• B. Done but not documented
• C. Not necessary to record
• D. The patient signed off

Answer: (A)

Documentation serves as the legal record of care and proof of what was done, when, and by whom. If a treatment is performed but not charted, there is no verifiable record to prove it happened, which in a legal sense means it was not done. This is why the chart is the definitive evidence of care and why missing documentation can be treated as if the treatment never occurred. Simply having a patient sign off does not substitute for written charting.