Documentation and Reporting · NCLEX Exam

What is the safest course of action if a nurse discovers that a paper chart is missing an entry about a significant change in a patient’s status?

  1. Insert the missing entry with that shift’s date and time.
  2. Wait until next shift to make the entry.
  3. Add an addendum noting the time you discovered the change.
  4. Delete the related entry to avoid confusion.
Show answer and explanation

Correct answer: Add an addendum noting the time you discovered the change.

If something was omitted, the safest course of action is to use an addendum noting the time you discovered the change — deleting or waiting is not recommended.

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