When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?

Choice A rationale

This statement provides objective and descriptive information about the patient's condition following the venipuncture. It accurately describes the physical findings (painful, raised hematoma) and the location (outer left arm) and clearly links it to the medical procedure (after venipuncture) without making assumptions or assigning blame.

Choice B rationale

This statement is inappropriate as it is judgmental and accusatory towards the laboratory technician. Medical documentation should be objective and focus on the patient's condition and care, not on personal opinions or unsubstantiated claims about the skills of healthcare professionals.

Choice C rationale

This statement is speculative and attempts to explain the cause of the hematoma without factual basis. While patient movement can contribute to bruising, stating it as a likely cause without evidence is not objective documentation and could be inaccurate.

Choice D rationale

While this statement is factual in that it describes the presence of a bruise, it lacks important details such as the size, characteristics (e.g., raised, painful), and its direct association with the venipuncture, which are relevant for a comprehensive patient record.

Choice A rationale

An incident report primarily focuses on documenting the facts of an event, not on preventing lawsuits. While a thorough report might indirectly help in legal defense by providing a clear record, its main purpose isn't legal protection. Legal strategies are separate from the incident reporting process.

Choice B rationale

Incident reports are crucial for a healthcare facility's quality improvement initiatives. By systematically documenting occurrences like patient falls, the hospital can analyze trends, identify potential risks and contributing factors, and implement strategies to prevent similar incidents in the future, thereby enhancing patient safety and care quality.

Choice C rationale

While incident reports from various units might be reviewed and compared as part of a broader quality improvement effort, the primary reason for completing an individual incident report is not solely for comparing fall rates between units. The immediate goal is to document the specific incident and identify local contributing factors.

Choice D rationale

Incident reports are designed to document events objectively. They are not primarily used as a basis for disciplinary action against a nurse. Disciplinary processes would involve a separate investigation to determine if negligence or policy violations occurred, based on various sources of information, not just the incident report.