Who is responsible for maintaining clinical records in accordance with facility policies?

The responsibility for maintaining clinical records in accordance with facility policies primarily falls to the Director of Nursing (DON) because this role encompasses oversight of nursing practice, quality of care, and compliance with regulations related to patient records. The DON plays a crucial role in ensuring that documentation is completed accurately and timely, as it is essential for patient care continuity, legal compliance, and quality improvement processes within the facility.

In addition, the Director of Nursing must ensure that all nursing staff are trained and adhere to facility policies regarding record-keeping. This position requires a comprehensive understanding of both clinical and administrative aspects of nursing practice, making it well-suited for overseeing the maintenance of clinical records.

While other roles, such as the facility administrator or medical staff, may have some responsibility related to policies or oversight, the specific duty of maintaining the accuracy and completeness of clinical records aligns most closely with the responsibilities of the Director of Nursing.