Question

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation?

1) Erase the incorrect statement and write the correct one.
2) Cross out the wrong statement in a way that is not readable.
3) Use correction fluid to obliterate what has been written.
4) Cross out the incorrect statement with a single line.

Answer 1

The best practice for recording an error in manual documentation is to cross out the incorrect statement with a single line, make a correction note, and ensure transparency of the documentation process.

Step-by-step explanation:

When a nurse makes a documentation error in a manual record sheet, the best practice is to cross out the incorrect statement with a single line so that the original entry is still readable. An entry should be made to indicate the correction, including the date, time, and signature or initials of the person who made the error. The correct information is then recorded. It is important not to obscure the original entry through erasing, using correction fluid, or crossing out in a way that makes the text unreadable, to maintain the integrity of the record and to ensure transparency of the documentation process.

Review Questions:
1. Each physician will explain their own procedures.
2. When you contact the technician, tell them the computer broke yesterday.
3. According to the guidelines, writers need to publish their manuscripts to be eligible for the grant.
4. If I ever meet a congressperson, I will tell them how upset I am with the politics at the national level.
5. When physicians want to order gloves, they must speak to the office staff.