The nurse realizes that the wrong vital signs were recorded on a patient's chart.
How will the nurse correct this error?
Use correction tape to write over the incorrect information.
Shred the forms with the incorrect information and write on new ones.
Black out the error with a thick marker and enter the correct information.
Draw one line through the error, make the correction, and initial it.
The Correct Answer is D
Choice A rationale
Using correction tape is inappropriate as it obscures the original entry, violating the principle of maintaining a clear and accurate audit trail. This makes it impossible to determine what the original error was and who made it, which is crucial for accountability and legal purposes in healthcare documentation.
Choice B rationale
Shredding the original forms and rewriting them is unacceptable because it completely eliminates the original record. This action could be interpreted as an attempt to conceal errors or misrepresent information, which carries significant legal and ethical implications in patient care documentation.
Choice C rationale
Blacking out the error with a thick marker obscures the original information, making it impossible to review the mistake and understand the context. This method does not allow for verification of the initial entry or tracking of the correction process, which is essential for maintaining accurate medical records.
Choice D rationale
Drawing a single line through the incorrect information, making the correction clearly beside it, and then initialing and dating the change maintains the integrity of the original record while indicating who made the correction and when. This method ensures transparency and accountability in documentation, adhering to legal and professional standards for error correction in medical charts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Increased technology awareness might be a consequence of EHR implementation, but it is not a primary advantage in terms of direct impact on patient care or healthcare delivery efficiency. The focus is on leveraging technology for improved outcomes.
Choice B rationale
EHRs facilitate seamless information sharing among healthcare providers, reducing reliance on paper-based records and improving coordination of care. This enhanced communication can lead to better-informed decision-making, reduced errors, and improved patient safety and outcomes.
Choice C rationale
The need for frequent technology updates can be a challenge associated with EHRs, requiring ongoing investment of time and resources for maintenance and training. This is a potential drawback rather than an advantage of electronic systems.
Choice D rationale
Required system changes, such as upgrades or modifications, can be disruptive and demand significant effort from healthcare organizations. While necessary for maintaining system functionality, they are not considered an inherent advantage of using EHRs.
Correct Answer is C
Explanation
Choice A rationale
SBAR (Situation, Background, Assessment, Recommendation) is a structured communication tool used for verbal or written reports, focusing on concise information transfer during transitions of care or urgent situations, not a comprehensive charting system based on exceptions.
Choice B rationale
Focused charting centers on specific patient problems or concerns, using a DAR (Data, Action, Response) format. It addresses particular issues in detail rather than documenting only deviations from the norm.
Choice C rationale
Charting by exception (CBE) is a documentation system where nurses only document findings that are outside the normal range or significant changes in a patient's condition. Standardized care and expected outcomes are assumed to be met and are not routinely documented, saving time and reducing redundancy.
Choice D rationale
SOAP (Subjective, Objective, Assessment, Plan) is a problem-oriented charting method commonly used by physicians and other healthcare providers to organize patient information around specific problems identified during assessment.
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