A nurse makes a documentation error in a paper record. What is the correct action?
Correct answer: C. Draw one line through it, then sign and date it.
- A. Erase the error and write the correct entry.
- B. Cover the error with correction fluid and rewrite it.
- C. Draw one line through it, then sign and date it.
- D. Remove the page and complete a replacement page.
Explanation
A single line keeps the original entry readable, while the nurse adds the correction, date, time, and signature according to facility policy. Erasing, using correction fluid, or removing a page damages the legal integrity of the record.
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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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