The nurse works in a small hospital that uses narrative documentation

QUESTION

The nurse works in a small hospital that uses narrative documentation rather than computer documentation. The nurse makes a practice of documenting care only at the end of the shift, just before giving shift report.

Which aspect of documentation credibility does this most clearly violate?
1. It is contemporaneous.
2. It is accurate.
3. It is truthful.
4. It is appropriate.

ANSWER:

Correct Answer: 1

Documentation should be contemporaneous (documented at the time it is provided), accurate, truthful, and appropriate. In this case, the most clearly violated aspect is that of being contemporaneous. Although documenting late may impact the accuracy and truthfulness of the notes, the nurse may be very accurate and very truthful, but just late in documenting. The documentation may be appropriate for the care provided even though it is late.