Final answer:
The charge nurse should first gather more information about the staff nurse's actions after observing incorrect documentation of a dressing change that was not performed. This step is crucial before deciding on further actions such as ensuring the dressing is changed, notifying management, or filling an incident report.
Step-by-step explanation:
If a charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed, the first action the charge nurse should take is to gather more information about the staff nurse's actions. This initial step is critical to understanding the situation fully before taking further action. By gathering more information, the charge nurse can confirm if the documentation was an oversight, a mistake, or intentional misconduct. It's important to address such issues promptly as they can affect patient care and the integrity of medical records.
Once the charge nurse has all the necessary information, they can then decide whether to ensure that the staff nurse changes the dressing, notify the nurse manager, or complete an incident report. The decision will depend on the specifics of the situation, such as the reason for the inaccurate documentation and the immediate needs of the patient.
Accurate documentation in healthcare is a legal and professional requirement, and any discrepancies must be handled by following the healthcare facility's protocols and standards.