A nurse is charting on a patient's record.Which action is most accurate legally?
A)Charting legibly.
B)Stating that the patient is belligerent.
C)Using correction fluid to correct error.
D)Writing entry for another nurse.

Question

Quizplus · Accepted Answer

The nurse should record all entries legibly.Personal opinions should be avoided;only objective and factual observations of patient's behaviour should be entered.All patient comments should be noted;for example,"Patient refuses to cough and deep breathe,saying,'I don't care what you say,I will not do it.'" Entries should not be erased,covered with correction fluid,or scratched out,even if they are in error.Charting should be done only by the nurse who performed the action or made the observation.

A Nurse Is Charting on a Patient's Record