When charting medication administration, which of the following is correct?
A. All chart entries must be factual, accurate, complete, current, organized, and confidential
B. Document your opinion of the patient's reaction to taking a medication
C. Skip a line after the last entry
D. Use your own shorthand to document
E. If you make a mistake, erase and correct the entry immediately
A. All chart entries must be factual, accurate, complete, current, organized, and confidential
Medical records are legal documents and are considered proof that a medication was given. They must be factual, accurate, complete, current, organized, and confidential.
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