Question

A charge nurse observes a staff nurse document a dressing change in a client's chart that was not performed. Which of the following actions should the charge nurse take first?

A) Confront the staff nurse about the false documentation
B) Document the correct information in the client's chart
C) Report the incident to the nursing supervisor
D) Notify the physician about the inaccurate documentation

Answer 1

The first action the charge nurse should take when observing false documentation is to confront the staff nurse responsible. This ensures that the incident is clarified and addressed directly to promote correction and prevent future occurrences.

Step-by-step explanation:

The charge nurse has observed a staff nurse document a dressing change in a client's chart that was not performed. In such a situation, the first action the charge nurse should take is A) Confront the staff nurse about the false documentation. This is because addressing the issue directly with the staff member can clarify the situation, promote honest communication, and if the documentation was falsely made, it can prevent it from occurring again. Ensuring accurate documentation is critical for patient safety, continuity of care, and legal compliance. The charge nurse could then proceed with additional actions as necessary, including formally reporting the incident and correcting the documentation.