A nurse is documenting patient care in the electronic health record (EHR) and realizes they made an error in documenting a medication dose. What action should the nurse take to address this legal and ethical issue?
Leave the error as is since it does not affect patient care.
Alter the documentation to reflect the correct medication dose.
Add an addendum to the documentation explaining the error and the correct medication dose.
Report the error to the supervisor or appropriate authority.
The Correct Answer is C
Add an addendum to the documentation explaining the error and the correct medication dose.
Accurate and timely documentation is essential for providing quality care and maintaining legal and ethical standards. In this situation, the nurse should add an addendum to the documentation, clearly explaining the error made in documenting the medication dose and providing the correct information. This ensures transparency, maintains the integrity of the record, and allows for accurate communication among healthcare providers.
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Option a (leaving the error as is) is inappropriate as it compromises the accuracy and reliability of the patient's health record, which may impact future care decisions.
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Option b (altering the documentation) is unethical and potentially illegal, as it involves falsifying information in the patient's record.
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Option d (reporting the error to the supervisor or appropriate authority) may be necessary, but the immediate action should be to address the error in the documentation itself.
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Correct Answer is C
Explanation
Remind colleagues about the importance of patient confidentiality and suggest discussing sensitive matters in private.
Maintaining patient confidentiality is a legal and ethical responsibility of healthcare professionals. In this situation, the nurse should remind colleagues about the importance of patient confidentiality and suggest discussing sensitive matters in a private, designated area. This action promotes ethical conduct, upholds patient rights, and helps create a culture of respect for privacy.
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Option a (joining the conversation and sharing experiences) contributes to the breach of patient confidentiality and does not address the issue.
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Option b (ignoring the conversation) passively allows the breach to continue and does not fulfill the nurse's responsibility to protect patient information.
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Option d (reporting the incident to the supervisor or appropriate authority) may be necessary if the breach persists or if the reminder is ignored. However, addressing the issue directly with colleagues is a proactive step that should be taken first.
Correct Answer is B
Explanation
Refuse to disclose the information and explain the importance of patient confidentiality.
Maintaining patient confidentiality is a fundamental ethical and legal obligation. In this situation, the nurse should refuse to disclose the information and explain to the family member the importance of patient confidentiality. Patient privacy and autonomy must be protected, and sharing information without consent can violate the patient's rights and confidentiality.
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Option a (sharing the information with the family member) is inappropriate without the patient's consent and violates patient confidentiality.
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Option c (informing the patient and seeking their consent) is a possible course of action, but the nurse's primary responsibility is to protect patient confidentiality.
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Option d (consulting with the healthcare provider) may be necessary in complex situations, but the initial response should be to refuse disclosure and explain the importance of patient confidentiality.
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