120k views
5 votes
Nurse completes documentation for pt and realizes entry was placed under wrong pt medical record. which action by nurse is most appropriate?

- complete incident report and place copy in pt's medical record
- draw single line through each line of incorrect entry and write new note explaining what happened
- use correction fluid to delete wrong and write in space note was obliterated for confidentiality
- copy note into correct record and indicate it was erroneously put in wrong chart

User Brian Hawk
by
7.9k points

1 Answer

4 votes

Final answer:

The most appropriate action for the nurse is to complete an incident report and place a copy in the correct patient's medical record. Drawing a line through the incorrect entry or using correction fluid is not recommended.

Step-by-step explanation:

In this scenario, the nurse accidentally placed documentation under the wrong patient's medical record. The most appropriate action for the nurse to take would be to complete an incident report and place a copy in the correct patient's medical record. This helps to ensure that the error is documented and can be addressed appropriately.

Other actions mentioned in the options, such as drawing a single line through each line of the incorrect entry and writing a new note, or using correction fluid to delete the wrong entry, are not recommended. These methods can potentially compromise the confidentiality and integrity of the patient's medical record. Additionally, copying the note into the correct record and indicating the mistake is a valuable step to fix the error and ensure accurate documentation.

Nurses must also review aloud with their team critical items related to patient care, such as name of the procedure, complete instrument counts, correct specimen labeling, and any equipment issues.

An incident report may also be necessary depending on the facility's policies to address and analyze the error so that future mistakes can be prevented. However, an incident report should not be placed in the patient's medical record as it is an internal document meant for tracking and improving hospital processes and safety.

User Sumner
by
8.2k points