A new nursing graduate has made an error in documentation that led to an unexpected client outcome. When aiming to avoid future errors, which action should the nurse prioritize?
Ensure charting entries are as concise as possible
Prioritize subjectivity over objectivity in documentation
Provide the greatest amount of detail possible in every charting entry
Complete documentation as soon as possible after client interactions
The Correct Answer is D
A. While concise documentation is valuable, being overly brief can lead to omission of important information.
B. Documentation should be objective, focusing on facts and observable data rather than subjective impressions.
C. Providing excessive detail can clutter the record and make it harder to identify critical information; relevance and clarity are more important than sheer volume.
D. Completing documentation as soon as possible after client interactions helps ensure accuracy and completeness. Timely documentation reduces the risk of forgetting important details and helps maintain continuity of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The defendant is the person being sued—in this case, the nurse.
B. A litigator is a lawyer who handles lawsuits, not the person bringing the suit.
C. The plaintiff is the person who initiates a lawsuit by filing a complaint against another party.
D. A witness is someone who provides testimony or evidence but is not a party to the lawsuit.
Correct Answer is C
Explanation
A. EMAR (Electronic Medication Administration Record) is a documentation tool, not a communication method.
B. SOAP (Subjective, Objective, Assessment, Plan) is a documentation format, not specifically for verbal communication.
C. ISBAR (Introduction, Situation, Background, Assessment, Recommendation) is a standardized communication technique designed to convey critical information clearly and efficiently, especially during telephone reporting.
D. CBE (Charting by Exception) is a documentation method focusing on deviations from norms, not a communication strategy.
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