Which of the following nurses has committed a serious documentation error?
a. Susan documents all medications for her patients prior to administration.
b. Jim documents medication administration as the medications are given.
c. Jane documents assessments as they are completed.
d. Jon documents meal intake as he picks up meal trays.
ANS: A
Documentation must be accurate to provide a realistic view of a patient's condition. Serious documentation errors include (1) omitting documentation from patient records, (2) recording assessment findings obtained by another nurse or unlicensed assistive personnel (UAP), and (3) recording care not yet provided. Nurses sometimes document that a patient has received medication before its administration; this is a serious violation of the law and becomes a medication error of omission if the nurse is distracted before administering the patient's medication.
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