A nurse is reviewing a previous nursing note and notices that it contains an unverified statement copied from an earlier entry. What is the best action?
Correct answer: C. Assess the patient and document verified findings
- A. Copy the statement again for consistency
- B. Delete the earlier nurse’s original entry
- C. Assess the patient and document verified findings
- D. Ignore the statement because it is already recorded
Explanation
The nurse should assess the patient and record only current findings that can be verified. Repeating unconfirmed information can spread an error and may compromise clinical decisions and legal accuracy.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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