Communication and Documentation Flashcards

A nurse makes an error while writing in a paper medical record. What is the correct way to fix it?

Answer: Draw a single line through the error, write 'error' or 'mistaken entry,' and add initials, date, and time

A single line keeps the original entry readable, which protects the legal integrity of the record.

A nurse realizes at the end of the shift that a dressing change done at 1000 was never documented. How should it be charted?

Answer: Chart it as a 'late entry' with the current date and time, noting that the care was done at 1000

Late entries must be clearly labeled and show both when they were written and when the care actually happened.

Which documentation entry is the most objective and appropriate?

Answer: "Client ambulated 50 feet in the hallway with a walker; reports pain 3/10 in the right hip."

Objective charting uses measurable, observable facts and the client's own pain ratings instead of judgments.

A client falls while getting out of bed. After caring for the client, how should the nurse handle the incident report?

Answer: Complete the incident report and chart only the factual details of the fall and care in the record

Incident reports are internal quality documents, so the chart describes the event and care but does not mention the report.

According to The Joint Commission's 'Do Not Use' list, how should the nurse document 10 units of regular insulin?

Answer: 10 units regular insulin

'U' and 'IU' can be misread as numbers, and trailing zeros can cause tenfold dosing errors, so 'units' should be written out without a trailing zero.

A facility uses charting by exception (CBE). What does this documentation system require?

Answer: Documenting only findings that differ from established normal standards

CBE assumes predefined normal findings and requires detailed notes only for abnormal findings or changes.

A client states, "I feel like my chest is being squeezed." How should the nurse document this?

Answer: Client states, "I feel like my chest is being squeezed."

Quoting the client's exact words is the most accurate way to record subjective data and avoids labeling or diagnosing.