Fundamentals of Nursing Q 35
At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take?
A. Complete an occurrence report before leaving.
B. Do nothing; the next nurse will document it was done.
C. Write the note of the dressing change into an earlier note.
D. Make a late entry as an addition to the narrative notes.
Correct Answer: D. Make a late entry as an addition to the narrative notes.
If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record the wound change as performed. A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care.
Option A: An occurrence report is not necessary in this case. The issue of completeness is important; Croke cites failure to document as one of the six top reasons that nurses face malpractice suits. In terms of overall completeness, Stokke and Kalfoss found many gaps in nursing documentation in Norway. Care plans, goals, diagnoses, planned interventions, and projected outcomes were absent between 18 percent and 45 percent of the time.
Option B: If documentation is omitted, there is no legal verification that the procedure was performed. Completeness of a record may have an impact on the quality of care, but only if it reflects completeness of the right content. Echoed again here is that document focus, rather than the patient-centric nature of the medical record, does little to support shared understanding by clinicians of care and the communication needed to ensure the continuity, quality, and safety of care.
Option C: It is illegal to add to a chart entry that was previously documented. The typical content and format of documentation—and its lack of accessibility—have also resulted in document-centric rather than patient-centric records.