Which of the following statements made by a nurse most reflects a need

Which of the following statements made by a nurse most reflects a need for additional instruc-tion on areas of client care requiring nursing documentation?

1. “The fact that the client refused the prescribed antidepressant medication was noted in his chart.”
2. “I provided a detailed description of the dressing change in the client’s chart in order to show it was done as prescribed.”
3. “The client’s wife told me he often develops a rash when he comes into contact with scented soaps, so I noted that in his chart.”
4. “I had a long conversation with the client concerning his fears about his upcoming surgery and I mentioned his concerns in my nursing note.”

ANSWER

ANS: 2
Common charting mistakes that can result in malpractice include the following: (1) failing to rec-ord pertinent health or drug information; (2) failing to record nursing actions; (3) failing to record that medications have been given; (4) failing to record drug reactions or changes in client’s con-dition; (5) writing illegible or incomplete records; and (6) failing to document a discontinued medication. Detailed descriptions of procedures are not included in the nursing notes.