A registered nurse in the United States is asked by a provider to enter a progress note with yesterday's date because the provider forgot to document the visit. What should the nurse do?
Correct answer: B. Enter the note using the current date and time
- A. Enter the note with yesterday's date as requested
- B. Enter the note using the current date and time
- C. Ask another nurse to enter the note instead
- D. Leave the note undocumented until the next shift
Explanation
The nurse should use the current date and time and identify any late entry according to policy. Altering the record's timing can be falsification and violates documentation integrity.
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About US Legal and Ethical Nursing Practice
US nursing law and ethics include state nurse practice acts, scope of practice, standards of care, negligence, malpractice, documentation, confidentiality under HIPAA and informed consent. Ethical reasoning applies autonomy, beneficence, nonmaleficence, justice and fidelity to conflicts such as refusal of treatment, advance directives, privacy breaches and mandatory reporting, which are not the same as legal liability.
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