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Author Question: The nurse has made an error and is documenting such on the client's record and notes. The action ... (Read 199 times)

09madisonrousseau09

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The nurse has made an error and is documenting such on the client's record and notes. The action that the nurse should take is to:
 
  1. Draw a straight line through the error and initial it.
  2. Erase the error and write over the material in the same spot.
  3. Use a dark color marker to cover the error and continue immediately after that point.
  4. Footnote the error at the bottom of the page.

Question 2

What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his cli-ents.
 
  1. Let me get the Registered Nurse on the phone.
  2. I am unable to take the order at this time. Please call in the morning.
  3. Please repeat the order for me so I can make sure it is written correctly.
  4. Let me have your phone number and I will have the supervisor call you back.



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tuate

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Answer to Question 1

ANS: 1
If a nurse has made an error in documentation, the nurse should draw a single line through the error, write the word error above it, and sign his or her name or initials. Then record the note correctly. The nurse should not erase, apply correction fluid, or scratch out errors made while re-cording because charting becomes illegible. Also, entries should only be made in ink so they cannot be erased. Using a dark color marker to cover the error is not correct. It may appear as if the nurse was attempting to hide something or deface the record. Footnotes are not used in nurs-ing documentation.

Answer to Question 2

ANS: 1
A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse. Saying that an order is unable to be taken and to call back in the morning is not an appro-priate response and not in the client's best interest. It is best to repeat any prescribed orders back to the physician, who can then verify if it is correct or clarify the order. This is not the appropriate response. A registered nurse needs to take the verbal order, but it does not have to be the nursing supervisor.





 

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