A nurse makes an incorrect entry in an electronic health record. What action preserves the record’s legal integrity?
Correct answer: B. Use the approved correction or addendum function
- A. Delete the entry and type a replacement
- B. Use the approved correction or addendum function
- C. Ask a colleague to change the entry under their login
- D. Leave the error because electronic records cannot be corrected
Explanation
The nurse should use the approved correction or addendum process so the original entry remains visible with an audit trail. Deleting entries or using another person’s login obscures accountability and may breach policy.
Report an error
The more specific you are, the faster it gets fixed. A source beats an opinion.
Prefer email? support@testustad.com
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.
Practise Documentation, Reporting and Communication
50 free Documentation, Reporting and Communication MCQs from Fundamentals of Nursing, each with the correct answer and an explanation. Unlimited attempts, no account needed.
Discussion
Stuck on an option, or know a faster way to get there? Ask or explain it here.
No comments yet. Be the first to explain this one.
Exams that ask Fundamentals of Nursing questions like this
Fundamentals of Nursing is on 9 papers prepared for on TestUstad, and all of them draw the same bank, so this question is worth knowing for every one of them.
More Documentation, Reporting and Communication questions
In the SOAP format, which information belongs in the assessment section?
A patient refuses a prescribed oral medication. Which documentation is most appropriate?
A nurse remembers an important assessment finding several hours after completing the original note. What is the correct way to document it?
During an SBAR handover, which statement belongs in the recommendation section?
A patient gives brief answers and avoids eye contact while discussing a new diagnosis. Which response best demonstrates therapeutic communication?
A nurse needs to share a patient’s clinical information with another member of the care team. Which practice best maintains confidentiality?