What fact is the nurse aware of when charting using paper nursing notes?
A) Use red ink so the nursing entries stand out.
B) When mistakes are made in documentation, the nurse should white out the entry.
C) Only one nurse should document on a sheet so that it can be removed in case of error.
D) The medical record, in any format, is the most reliable source of information in a legal action.

Question

Quizplus · Accepted Answer

The medical record is seen as the most reliable source of information in any legal action related to care. When legal counsel is sought because of a negative outcome of care, the first action taken by an attorney is to acquire a copy of the medical record. Ink color is usually black, blue or other as designated by the facility. Notes should never be altered or obliterated. Documentation mistakes must be acknowledged. If an error is made in paper documentation, a line is drawn through the error and the word error is placed above or after the entry, along with the nurse's initials and followed by the correct entry.

What Fact Is the Nurse Aware of When Charting Using