A registered nurse in the United States sees a colleague enter a medication administration record for a dose that the colleague did not give. What should the nurse do?
Correct answer: B. Ask the colleague to correct the record through policy
- A. Delete the entry to prevent an inaccurate record
- B. Ask the colleague to correct the record through policy
- C. Document the dose as given based on the colleague's entry
- D. Wait until discharge before mentioning the concern
Explanation
The nurse should address the falsified or inaccurate documentation promptly through the facility's correction and reporting process. Records must remain accurate, and the nurse should not alter another person's entry or conceal the concern.
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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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