A nurse manager on the OB unit is auditing patient charts. One record documents the care of a patient having a seizure. The record describes the time and length of the seizure, medications given, maternal and fetal vital signs, and outcome of treatment
Which action by the manager is best?
A.
Compare the chart with charts of similar patients.
B.
Educate the staff on better documentation practices.
C.
Have the nurse rewrite the documentation.
D.
No action is needed; continue with chart audits.
ANS: B
The elements of complete documentation include what was charted plus associated symptoms, presence (or absence) of uterine contractions, and the presence of other obstetrical complications (e.g., rupture of membranes). The manager should educate all nurses in the unit about complete documentation needed for patients having a seizure. There is no need to compare this chart with others, and the nurse should not rewrite the documentation (although the nurse may need to use an addendum, depending on how old the record is).
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