hard · NCLEX-RN Management of Care
The nurse is documenting a complex clinical event involving a medication error. Which documentation practices follow the 'Safe and Effective Care' standards? Select all that apply.
- Correct a previous error by erasing the text completely and writing over it to keep the chart clean.
- Enter the date and time of the event as it occurred, even if the entry is recorded later in the shift.
- Include the client's physiological response to the error and the interventions performed to ensure safety.
- Avoid documenting that an incident report was filed in the client's permanent medical record.
- Use phrases such as 'the pharmacy was careless' to explain why the error occurred.
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