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posiodensgurl posiodensgurl
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6 years ago
The charge nurse is evaluating the documentation of the new staff nurse. Based on which of the following does the charge nurse note, on review of the charting, that appropriate documentation is evident?
 
  a. The new staff nurse used a pencil to make the entries.
  b. The new staff nurse used correction fluid to correct written errors.
  c. The new staff nurse identified an error made by the attending physician.
  d. The new staff nurse has dated and signed all of the entries he or she made in the record.
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wrote...
6 years ago
D
Each entry should begin with the time of entry and end with the signature and title of the nurse who recorded the entry.
All entries should be recorded legibly and in black ink because pencil can be erased.
The nurse should never erase entries or use correction fluid, and never use a pencil. The use of correction fluid could render the charting illegible, and it may appear as if the nurse were at-tempting to hide something or deface the record.
If the physician made an error, the nurse should not document it in the client's chart; the error should be documented in an incident report.
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