Which action makes a handwritten nursing entry legally complete?
Correct answer: A. Adding the date, time, signature, and professional designation
- A. Adding the date, time, signature, and professional designation
- B. Writing the entry at the end of the shift without a time
- C. Using the initials of another nurse who witnessed the care
- D. Leaving space so another nurse can add further information
Explanation
A nursing entry should identify when the care occurred and who documented it, including the nurse’s signature and professional designation. An untimed or unidentified entry weakens continuity of care and legal accountability.
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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.
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