Difficulty: Medium
Average Score: 71%
Simulated
A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)
Correct answer
D,E
Rationale
D: Documentation must be objective (e.g., 'grimaced when moving') to avoid bias. E: Including date and time ensures a clear timeline for legal and care continuity. A is incorrect because timely documentation prevents errors. B is incorrect as errors should be corrected with a single line and initials. C is incorrect because only approved abbreviations should be used to avoid confusion.