The nurse is charting using paper nursing notes. The nurse is aware that:
A) attorneys are not allowed access to medical records during litigation.
B) when mistakes are made in documentation, the nurse should scribble 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 is the most reliable source of information in any 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. 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.

The Nurse Is Charting Using Paper Nursing Notes