Hard

A nurse makes a documentation error in an electronic health record. Which action is legally appropriate?

Correct answer: C. Correct it according to the system audit process

  • A. Delete the entry without an explanation
  • B. Ask a colleague to rewrite the entry
  • C. Correct it according to the system audit process
  • D. Leave the error because records cannot be changed

Explanation

An electronic record should be corrected through the approved amendment process so that the original entry and the correction remain traceable. Deleting or secretly changing a record can be viewed as falsification.

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About Legal Aspects and PNMC Regulation

Legal aspects of nursing include professional scope of practice, registration and licensing, standards of care, negligence, malpractice, assault, battery, consent, confidentiality and accurate documentation. PNMC regulation also involves professional accountability, disciplinary procedures and safe delegation, which differ from ethical guidance because they carry legal or regulatory consequences.

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