The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse:
1. Uses a pencil to make the entries
2. Uses correction fluid to correct written errors
3. Identifies an error made by the attending physician
4. Dates and signs all of the entries made in the record
ANS: 4
Each entry should begin with the time and end with the signature and title of the person record-ing the entry. All entries should be recorded legibly and in black ink because pencil can be erased. The nurse should never erase entries, never use correction fluid, or never use a pencil. The use of correction fluid could make the charting become illegible and it may appear as if the nurse were attempting to hide something or to deface the record. If the physician made an error, the nurse should not document it in the client's chart. It should be documented in an incident report.
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