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. Guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal. Protecting patient confidentiality is essential in electronic charting to prevent unauthorized access.
B. Learning the passwords of the staff nurses and primary care providers so that they can communicate with one another. Sharing or learning others' passwords violates security protocols and confidentiality rules.
C. Choosing whether he will use the computer to help in documentation or continue to use traditional paper documentation. In facilities using electronic charting, all staff are typically required to use the system to maintain consistent, accessible records.
D. Patient education to input information about herself, such as intake and output or symptoms the patient may experience. Patients typically do not have access to chart directly into their medical records.
Correct Answer is D
Explanation
A. Avoid the use of eye contact to allow the patient to express herself without feeling stared at or demeaned.
Avoiding eye contact can make the patient feel ignored or unheard and is generally not effective in active listening.
B. Ask probing questions to direct the conversation and obtain the information needed as efficiently as possible.
Active listening involves allowing the patient to lead the conversation rather than directing it with probing questions.
C. Anticipate what the speaker is trying to say and help the patient express herself when she has difficulty with finishing a sentence.
While well-intentioned, finishing sentences can prevent the patient from expressing thoughts fully.
D. Use nonverbal cues such as leaning forward, focusing on the speaker's face, and slightly nodding to indicate that the message has been heard.