The nurse is charting using paper nursing notes. The nurse is ...

[humphriesbr@me.com]

The nurse is charting using paper nursing notes. The nurse is aware that:
 
  a. attorneys are not allowed access to medical records during litigation.
  b. when mistakes are made in documentation, the nurse should scribble out the entry.
  c. only one nurse should document on a sheet so that it can be removed in case of error.
  d. the medical record is the most reliable source of information in any legal action.

Question 2

If a verbal or phone order is necessary in an emergency, the order:
 
  a. must be taken by an RN or LPN.
  b. must be repeated verbatim to confirm accuracy.
  c. documented as a written order.
  d. does not need further verification by the provider.

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Answer to Question 1

ANS: D
The medical record is seen as the most reliable source of information in any legal action related to care. When legal counsel is sought because of a negative outcome of care, the first action taken by an attorney is to acquire a copy of the medical record. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurse's initials and followed by the correct entry.

Answer to Question 2

ANS: B
If a verbal or phone order is necessary in an emergency, the order must be taken by a registered nurse (RN) who repeats the order verbatim to confirm accuracy and then enters the order into the paper or electronic system, documenting it as a verbal or phone order and including the date, time, physician's name, and RN's signature. Most facility policies require the physician to co-sign a verbal or telephone order within a defined time period.

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TYSM

[chereeb]

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