A nurse is manually documenting information related to a client's ...

[beccaep]

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error. Which is the best technique for correcting the error made in documentation?
 
  A) Erase the incorrect statement and write the correct one.
  B) Cross out the wrong statement in a way that is not readable.
  C) Use correction fluid to obliterate what has been written.
  D) Cross out the incorrect statement with a single line.

Question 2

When documenting information in a client's medical record, which of the following should the nurse do consistently for each entry?
 
  A) Report each observation to the physician.
  B) Sign each entry by name and title.
  C) Obtain a signature from the physician.
  D) Provide the day of the week on the entry.

[LegendaryAnswers]

Answer to Question 1

D
Feedback:
When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one, cross out the wrong statement in a way that means the statement is not readable, or use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.

Answer to Question 2

B
Feedback:
When documenting information in a client's medical record, the nurse should sign each entry by name and title. It is not necessary for the nurse to report every observation to the physician. Obtaining a signature from the physician is not absolutely essential. The nurse need not enter the day of the week for each entry, but the nurse must enter the date and time for each entry.