The nurse is charting in the paper medical record. She should:
a. print his/her name since signatures are often not readable.
b. not document her credentials since everyone knows that she is a nurse.
c. skip a line, leaving a blank space, between entries so that it looks neater.
d. use black ink unless the facility allows a different color.
ANS: D
Entries into paper medical records are traditionally made with black ink to enable copying or scanning, unless a facility requires or allows a different color. The date, time, and signature, with credentials of the person writing the entry, are included in the entry. No blank spaces are left between entries because they could allow someone to add a note out of sequence.
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