Question

A nurse is documenting a client's blood pressure in his medical record. She is using a pencil to note the blood pressure reading in the chart. Why is a pencil not a good tool to use in writing down blood pressure?

A.There is no reason why she cannot use a pencil to write down pertinent medical information.
B.She should have used an erasable pen instead of a pencil.
C.She should have used a highlighter with the pencil to indicate permanence of the finding.
D.She should use black or blue ink, because whatever is written in the chart should be permanent.

Answer 1

Using a pencil for medical documentation is not recommended because it can be altered, making it essential to use permanent ink to ensure the medical record's accuracy and integrity, especially for vital measurements like blood pressure.

Step-by-step explanation:

When documenting a client's blood pressure in the medical record, the use of a pencil is not considered best practice because it allows for the information to be altered or erased, which can compromise the accuracy and integrity of the medical record. Instead, healthcare professionals should use permanent black or blue ink when recording medical information to ensure that records are clear, permanent, and unalterable, which is crucial for maintaining accurate medical histories and for medico-legal reasons. The nature of blood pressure measurement using a sphygmomanometer, whether manual or digital, requires precise and unchangeable documentation for effective patient management and care.

Recording blood pressure readings accurately is important as these measurements can influence treatment decisions. For instance, the presence of hypertension or fluctuations in blood pressure could indicate various health issues that require prompt and accurate intervention. Therefore, maintaining proper records is essential for ongoing patient care and communication among healthcare providers.