How should the nurse correct an error in charting? a. remove ...

[kshipps]

How should the nurse correct an error in charting?
 
  a. remove the sheet with the error and replace it with a new sheet with the correct entry.
  b. scribble out the error and rewrite the entry correctly.
  c. draw a single line through the error, and then write error above or after the entry
  d. leave the entry as is and tell the charge nurse.

Question 2

The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. The best central location to obtain this information is the:
 
  a. admission summary.
  b. discharge summary.
  c. flow sheet.
  d. Kardex.

[frejo]

Answer to Question 1

ANS: C
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. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged.

Answer to Question 2

ANS: A
An admission summary includes the patient's history, a medication reconciliation, and an initial assessment that addresses the patient's problems, including identification of needs pertinent to discharge planning and formulation of a plan of care based on those needs. The discharge summary addresses the patient's hospital course and plans for follow-up, and it documents the patient's status at discharge. It includes information on medication and treatment, discharge placement, patient education, follow-up appointments, and referrals. Flow sheets and checklists may be used to document routine care and observations that are recorded on a regular basis, such as vital signs, medications, and intake and output measurements. Although computerization of records may mean that the Kardex system is no longer active, the term kardex continues to be used generically for certain patient information held at the nurses' station.

[kshipps]

Both answers were spot on, thank you once again

[frejo]

Great! Please up vote