Question

The nurse understands that patient records are legal documents and should be accurate. What precautions should the nurse take when documenting? Select all that apply.

1. Record all facts.
2. Apply correction fluid on errors.
3. Record all written entries legibly and in black ink.
4. Begin each entry with date and time and end with signature and title.
5. Leave blank spaces in the nurse's note to fill in the details later.

Answer 1

When documenting patient records, nurses should record all facts, write legibly and in black ink, and include the date, time, signature, and title.

Step-by-step explanation:

When documenting patient records, nurses should take the following precautions:

1. Record all facts: Document all relevant information in an objective and unbiased manner.
2. Record all written entries legibly and in black ink: This ensures that the information is clear and easy to read.
3. Begin each entry with the date and time and end with signature and title: This provides a clear timeline of events and establishes accountability.

Applying correction fluid should not be done because it can compromise the integrity of the record. Leaving blank spaces in the nurse's note is also not recommended as it can lead to incomplete or inaccurate information.