Ethical and Legal Considerations in Documenting and Reporting
Ethical and Legal Considerations in Documenting and Reporting ( 5 Questions)
A nurse is using a computerized system to document and report client information.
The nurse realizes that an entry error has been made in the system.
What should the nurse do to correct the error?
Deleting the erroneous entry may not be possible or appropriate in some systems, and it may compromise the integrity and auditability of the documentation.
Drawing a line through the erroneous entry and initialing it is a method for correcting errors in paper documentation, not computerized documentation.
Follow the facility’s policy and procedure for correcting an entry error. This is because different computerized systems may have different methods for correcting errors, and the nurse should follow the guidelines of the specific system and facility to ensure accuracy, accountability and legal compliance.
Ignoring the error and hoping that no one notices it is unprofessional, unethical and potentially dangerous for the patient’s care and safety.
Follow the facility’s policy and procedure for correcting an entry error. This is because different computerized systems may have different methods for correcting errors, and the nurse should follow the guidelines of the specific system and facility to ensure accuracy, accountability and legal compliance.
Choice A is wrong because deleting the erroneous entry may not be possible or appropriate in some systems, and it may compromise the integrity and auditability of the documentation.
Choice B is wrong because drawing a line through the erroneous entry and initialing it is a method for correcting errors in paper documentation, not computerized documentation.
Choice D is wrong because ignoring the error and hoping that no one notices it is unprofessional, unethical and potentially dangerous for the patient’s care and safety.
The nurse should always document accurately, promptly and honestly, and report any errors or discrepancies in the documentation to the appropriate authority.