Documentation and record privacy practices

Question

Click to highlight the findings that require follow-up.

Unit documentation walk-through, 1500. The computer at station 3 stayed open on a client's medication record, screen facing the hallway, while the nurse was in the supply room. A nursing assistant covered a wrong weight on the paper flow sheet with correction fluid. The nurse gave the 1000 stool softener and waited until after lunch to chart it. Another nurse locked her workstation before stepping away. The nursing assistant told the nurse about a new blood pressure right away and then charted it. A progress note from the physical therapist was read by the nurse before planning afternoon care.

Highlighted phrases are the correct selections.

Answer

The computer at station 3 stayed open on a client's medication record, screen facing the hallway, while the nurse was in the supply room. · A nursing assistant covered a wrong weight on the paper flow sheet with correction fluid. · The nurse gave the 1000 stool softener and waited until after lunch to chart it.

Rationale

An unattended open screen exposes client information to passersby, so it needs follow-up. Covering a paper-chart error with correction fluid hides the original entry; the accepted method is a single line, a label and initials. Medication charting delayed for hours risks a second nurse repeating the dose. The other findings show appropriate protection of records, prompt reporting and use of team notes.