NU 311: Legal Documentation Guidelines for Nursing Notes | Questions with
100% Verified Answers | Latest Update
Question: Error Correction
Answer:
Draw a single line through the error, write the word 'error' above it, and sign your name or
initials.
Question: Adding Information
Answer:
If additional information needs to be added to an existing entry, write the date and time of the
new entry on the next available space, and mark it as an addendum.
Question: Comments on Care
Answer:
DO NOT write retaliatory or critical comments about patient or care by other health care
professionals.
Question: Objective Descriptions
Answer:
Enter only objective descriptions of patient's behavior, use quotations for patients comments.
Question: Charting Accuracy
Answer:
DO NOT rush to complete charting; make sure information is accurate.
Question: Error Correction Promptness
Answer:
Correct ALL errors promptly.
Question: Speculation in Entries
Answer:
DO NOT speculate or guess while making entries, make sure to state the facts.
Question: Fact Recording
Answer:
Record ALL the facts, so that the information is accurate and reliable.
100% Verified Answers | Latest Update
Question: Error Correction
Answer:
Draw a single line through the error, write the word 'error' above it, and sign your name or
initials.
Question: Adding Information
Answer:
If additional information needs to be added to an existing entry, write the date and time of the
new entry on the next available space, and mark it as an addendum.
Question: Comments on Care
Answer:
DO NOT write retaliatory or critical comments about patient or care by other health care
professionals.
Question: Objective Descriptions
Answer:
Enter only objective descriptions of patient's behavior, use quotations for patients comments.
Question: Charting Accuracy
Answer:
DO NOT rush to complete charting; make sure information is accurate.
Question: Error Correction Promptness
Answer:
Correct ALL errors promptly.
Question: Speculation in Entries
Answer:
DO NOT speculate or guess while making entries, make sure to state the facts.
Question: Fact Recording
Answer:
Record ALL the facts, so that the information is accurate and reliable.
