After leaving work, a staff nurse realizes that documentation of the administration of a medication to a patient was omitted. This off-duty nurse telephones the unit and tells the nurse,
"Please document the administration of the medication I forgot to do. My password is alpha1." The nurse should:
a. fulfill the request.
b. refer the matter to the charge nurse to resolve.
c. access the record and document the information.
d. report the request to the patient's health care provider.
ANS: B
At most hospitals, termination is a possible penalty for unauthorized entry into a patient record. Referring the matter to the charge nurse will allow the observance of hospital policy while ensuring that documentation occurs. Making an exception and fulfilling the request places the on-duty staff nurse in jeopardy. Reporting the request to the patient's health care provider would be unnecessary. Accessing the record and documenting the information would be unnecessary when the charge nurse can resolve the problem.
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