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. Silence. Silence can be challenging for nursing students as it requires them to resist the urge to fill quiet moments, allowing the patient time to think or express emotions.
B. Closed questions. Closed questions are relatively straightforward and easy to use, often requiring only simple responses.
C. Using general leads. General leads encourage patients to continue sharing and are easier for most students than silence.
D. Restating. Restating is often easier for students, as it involves repeating back what the patient has said for clarity.
Correct Answer is B
Explanation
A. is packing belongings in preparation for discharge. Although discharge is an appropriate time for patient education, it may be too late to introduce complex information that requires practice or understanding. Teaching moments often occur earlier in the care process.
B. says, "How will I remember all the things about my new diet?" This is an ideal teaching moment as the patient is expressing concern and showing readiness to learn about the diet. The nurse can use this moment to provide guidance on strategies to remember dietary instructions.
C. has just returned from surgery for a deviated septum. Immediately post-surgery, the patient may be under the influence of anesthesia or pain medication, limiting their ability to absorb information. Teaching at this time may not be effective.
D. has just been told of the malignancy of his tumor. Right after receiving bad news, patients may experience shock, grief, or distress, making it difficult for them to process additional information. This may not be the right time for education.