Author Question: What are categories of inadequate documentation that may lead to a malpractice claim? (Select all ... (Read 23 times)

Collmarie · **on:** Jul 23, 2018

What are categories of inadequate documentation that may lead to a malpractice claim? (Select all that apply.)

a. Incorrectly recording the time of an event
b. Failing to record verbal orders
c. Charting events in advance
d. Documenting an incorrect date
e. Marking out and initialing charting errors

Question 2

What should the nurse be sure to do when documenting in a patient's chart?

a. Include speculation
b. Chart consecutively
c. Leave blank spaces
d. Include retaliatory comments

vboyd24 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: A, B, C, D
Marking out with a single line and initialing is an acceptable method to indicate a charting error.

Answer to Question 2

ANS: B
A nurse should not write retaliatory or critical comments about a patient or care by other health care professionals. The nurse should not leave blank spaces in the nurse's notes. The nurse should be certain the entry is factual and not speculate or guess. The nurse should chart consecutively, line by line.