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?
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.
Keep practicing
More Documentation and Reporting questions
- Which documentation entry is most appropriate after giving a PRN pain medication?
- During shift-handoff report, what should the 'A' (Assessment) contain in the SBAR format?
- Why might documenting 'Patient is unstable at this time' be problematic?
- Which of the following best reflects a guideline for accurate charting?
- Under the “Charting by Exception” (CBE) method, which statement is true?
- What violation does a nurse likely commit by using a personal mobile device to photograph a patient’s wound for documentation without verif…