While giving an end-of-shift report at 1915, a nurse realizes ...

[laurencescou]

While giving an end-of-shift report at 1915, a nurse realizes that a client's physical therapy session that occurred at 1030 was not documented. Which of the following is the correct method for adding this information to the client record?
 
  a. Ask the oncoming nurse to make the notation for you.
  b. Date and time the entry for 1915; then write Late Entry (date-1030) before making the addition.
  c. Do not add the information to the chart, but complete an incident report.
  d. Do nothing, since the physical therapist documented the session in the multidisciplinary progress notes.

Question 2

If a nurse makes a mistake while charting, which of these actions is correct?
 
  a. Black out the entry so that it cannot be read; then date, time, and initial the entry.
  b. Cross out the entry with a single line; then write mistaken entry with date, time, and initials.
  c. Erase the entry if possible.
  d. Use correction fluid to obliterate the incorrect entry; then enter the correct notation over the previous one.

[mjenn52]

Answer to Question 1

B
Entries should be made chronologically, starting with date and time, observation, intervention, and evaluation; it is essential to chart periodically throughout the period in which care is being provided so that significant changes in client condition are recorded as they occur. If pertinent data are not documented in a timely manner, late entries to a client's record may be permitted, according to facility policy.

Answer to Question 2

B
It is essential that the nurse use factual, descriptive terms to document procedures that were observed or performed, and complete sentence structure, with correct spelling and grammar. If an error in documentation occurs, the nurse should cross out the entry with a single line and then write mistaken entry with date, time, and initials.

[laurencescou]

TY

[mjenn52]

You're welcome