A nurse enters a notation in a patient's medical record but then discovers that the notation was made in the wrong chart. The nurse correctly:
follows agency policy for correcting the error.
whites out the wrong entry and writes the note in the chart of the correct patient.
removes the page on which the error is located and documents the other correct notes.
blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time.
The Correct Answer is A
A. Follows agency policy for correcting the error.
Following agency policy is the best approach, as it ensures compliance with legal and procedural standards for correcting documentation errors.
B. Whites out the wrong entry and writes the note in the chart of the correct patient. Whiting out errors is not permissible, as it can appear as an attempt to alter records and compromises the integrity of documentation.
C. Removes the page on which the error is located and documents the other correct notes. Removing pages from a medical record is improper and could be considered tampering with documentation.
D. Blacks out the note to protect the confidentiality of the patient about whom it was written and writes in the margin "wrong patient," his signature, and the date and time.
Blacking out notes is not allowed, as it destroys information that should remain legible, even if it was written in error.
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Correct Answer is A
Explanation
A. Uses short, simple sentences.
Short, simple sentences are easier to understand and support clear communication.
B. Shouts repeatedly at the patient.
Shouting can distort sounds and may be uncomfortable or disrespectful for the patient.
C. Speaks directly into the patient's ear.
Speaking directly into the ear is not appropriate as it can invade personal space and may not improve understanding.
D. Uses long, complex sentences.
Long sentences may be harder for the patient to understand, especially if lip-reading is being used.
Correct Answer is C
Explanation
A. "Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch."
This documentation provides details but lacks specific information on the pain’s nature and duration.
B. "Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch."
This statement includes diet details but lacks a pain intensity rating and specific location.
C. "Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids." This statement is the most thorough, including location, nature, intensity, duration, and lack of relief from interventions.
D. "Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse."
This is incomplete, as it lacks a specific location and description of the pain’s onset.