A nurse notices that a completed paper nursing record has been removed from the chart by another staff member. What should the nurse do first?

Correct answer: B. Report the missing record through the approved chain of command

  • A. Replace it with a newly written record from memory
  • B. Report the missing record through the approved chain of command
  • C. Ignore it because the information may be available elsewhere
  • D. Remove another entry to keep the chart balanced

Explanation

Removing a clinical record can compromise patient safety, continuity of care and legal evidence. The nurse should promptly report the missing document through the approved chain of command and should not recreate or destroy records improperly.

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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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