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Documentation and Reporting
Documentation and Reporting ( 6 Questions)
A nurse is preparing to document a client's wound assessment in the electronic health record.
Which of the following actions should the nurse take?
The nurse should include the date and time of the wound assessment in the documentation, as this provides a chronological and accurate record of the client's condition and response to treatment.
This is a partially correct statement, as the nurse should use abbreviations that are approved by the facility to ensure clarity and consistency in the documentation. However, this is not the best answer, as some abbreviations may still be confusing or ambiguous, and should be avoided or spelled out.
This is an incorrect statement, as copying and pasting the previous assessment as a template can result in errors, omissions, or duplication of information, compromising the quality and integrity of the documentation.
This is an incorrect statement, as deleting any entries made by other staff members is unethical and illegal, as it alters the original record and may affect the client's care or legal outcomes. The nurse should follow the facility's policy on correcting errors in documentation, which usually involves drawing a single line through the error, writing "error" above it, and signing and dating it.
Include the date and time of the assessment.
Rationale: The nurse should include the date and time of the wound assessment in the documentation, as this provides a chronological and accurate record of the client's condition and response to treatment.
Incorrect options:
B) Use abbreviations that are approved by the facility. - This is a partially correct statement, as the nurse should use abbreviations that are approved by the facility to ensure clarity and consistency in the documentation. However, this is not the best answer, as some abbreviations may still be confusing or ambiguous, and should be avoided or spelled out.
C) Copy and paste the previous assessment as a template. - This is an incorrect statement, as copying and pasting the previous assessment as a template can result in errors, omissions, or duplication of information, compromising the quality and integrity of the documentation.
D) Delete any inaccurate entries made by other staff members. - This is an incorrect statement, as deleting any entries made by other staff members is unethical and illegal, as it alters the original record and may affect the client's care or legal outcomes. The nurse should follow the facility's policy on correcting errors in documentation, which usually involves drawing a single line through the error, writing "error" above it, and signing and dating it.