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 C
Explanation
A. Speaking slowly and clearly in the patient's native language. While speaking clearly in the patient’s native language is helpful, it does not verify understanding. Feedback from the patient is necessary to confirm comprehension.
B. Asking the family members whether the patient understands. Relying on family members may not be accurate, as they may not fully understand the patient's level of comprehension.
C. Obtaining feedback from the patient that indicates accurate comprehension. Having the patient repeat the information back or summarize it in their own words ensures they have understood the communication.
D. Checking for signs of hearing loss or aphasia before communicating. Assessing for hearing loss or aphasia can be part of the process but does not confirm that communication was understood.
Correct Answer is C
Explanation
A. Asking the patient, "Did you graduate from high school?" This question is not a direct way to assess reading or comprehension ability. A person’s educational level does not necessarily reflect literacy skills.
B. Giving the patient a printed instruction sheet and saying, "Some people have difficulty with written instructions. Others find them helpful. Would these be helpful to you?" This approach is indirect and does not confirm whether the patient can actually read or understand the instructions.
C. Giving the patient some printed materials and saying, "After you have read this, I'll ask you some questions about what's in them, to see if you've learned it." This option allows the nurse to assess both the patient's reading ability and understanding by following up with questions, ensuring comprehension.
D. Asking the patient, "Are you able to read?" While this question is direct, it may embarrass the patient, and it does not assess comprehension.