A nurse working in a care area that uses paper charting notices an error when recording a patient’s vital signs in the patient record.
Which option adheres to The Centers for Medicare & Medicaid Services (CMS) guidelines for making corrections to documentation?
The nurse may use white out to remove the incorrect documentation and write the correct information over the white out.
The nurse should use a permanent marker to eliminate all incorrect documentation from view and initial the mistake.
The nurse should cross out the error with a double line so the original documentation may be seen and date the new entry.
The nurse should cross out the error with a single line so the original documentation can be seen and sign and date the correction.
The Correct Answer is D
Choice A rationale
Using white out to remove incorrect documentation and writing the correct information over the white out is not an acceptable practice according to CMS guidelines. This method does not allow for the original documentation to be seen, which is a requirement for making corrections to documentation.
Choice B rationale
Using a permanent marker to eliminate all incorrect documentation from view and initialing the mistake is also not an acceptable practice according to CMS guidelines. This method completely obscures the original documentation, which goes against the CMS requirement that all original content must be clearly identifiable.
Choice C rationale
Crossing out the error with a double line so the original documentation may be seen and dating the new entry is not specifically mentioned in the CMS guidelines. While this method does allow for the original documentation to be seen, it’s not clear whether it adheres to all CMS guidelines.
Choice D rationale
According to CMS guidelines, when making corrections to documentation, the nurse should cross out the error with a single line so the original documentation can be seen and sign and date the correction. This method ensures that all original content is clearly identifiable, which is a requirement for making corrections to documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
A potassium level of 6.4 mmol/K is above the normal range (3.5-5.0 mmol/L) and can be life- threatening. High potassium levels can lead to dangerous heart rhythms.
Correct Answer is A
Explanation
Choice A rationale
Unfreezing is the first stage of Lewin’s Change Theory. It involves overcoming resistance to change and preparing for the upcoming change. In this case, the patient expressing interest in quitting smoking and asking about smoking cessation aids indicates that they are in the unfreezing stage.
Choice B rationale
Moving is the second stage of Lewin’s Change Theory. It involves taking the necessary steps towards change.
Choice C rationale
The term “Action” is not recognized as a stage in Lewin’s Change Theory.
Choice D rationale
Refreezing is the final stage of Lewin’s Change Theory. It involves establishing the change as a new habit, so it becomes the "norm"4.
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