A newly licensed nurse documents care for a hospitalized client. Which actions are appropriate? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
The health record should identify what occurred, when it occurred, and who documented it. Chart care promptly after it is performed, in chronological order, and authenticate the entry according to policy (Choice 1). Use the organization's approved terminology and avoid prohibited or error-prone abbreviations and dose expressions (Choice 3); The Joint Commission publishes a minimum Do Not Use list rather than a universal list of approved abbreviations. Never chart care before it occurs (Choice 2). Correct paper-record errors by the policy-approved method that preserves the original entry and audit trail, not with correction fluid or tape (Choice 4). Each user must access the electronic record with an individual credential so actions remain attributable (Choice 5). Document objective, relevant observations and direct client statements rather than unsupported labels or opinions (Choice 6).
Clinical Judgment The chart is a legal document. Apply two filters before each entry: Did it actually happen, and is it objective? If not, do not chart it.
Memory Tip F-A-C-T charting: Factual + Accurate + Complete + Timely. Add a fifth — sign every entry with name and credentials.
KR vs US US accreditation (TJC) audits unapproved abbreviations and password sharing as serious patient-safety violations. In Korea, hospital-specific abbreviations are sometimes tolerated, but NCLEX-RN expects strict adherence to the ISMP/TJC Do Not Use list and to individual EHR logins.
Clinical Practice GuideANA Principles for Nursing Documentation and TJC Record of Care standards require entries that are factual, accurate, complete, and timely, with no blank lines and no charting in advance. Approved formats include SOAP, SOAPIE, DAR/FOCUS, and PIE. The ISMP Do Not Use list (for example, U for units, QD, MS, trailing zeros) prevents tenfold dosing errors.
CautionCommon NCLEX traps: white-out as a fix, charting ahead, sharing logins, and writing opinions. The chart goes to court — if it was not charted, it was not done, and anything charted incorrectly can be used against the nurse.
ISMP Do Not Use List — A list of error-prone abbreviations, symbols, and dose designations that should never be used in clinical documentation. Examples include U (use "units"), QD/QOD (use "daily", "every other day"), trailing zeros (1.0 mg → 1 mg), and lack of leading zero (.5 mg → 0.5 mg). NCLEX exam tip: any abbreviation on the ISMP/TJC Do Not Use list is wrong even if the rest of the entry is correct.
Late Entry — An entry made after the time the event occurred but as soon as the omission is discovered. Mark clearly as "Late entry for [date and time]" followed by the actual content, then date, time, and signature of the late entry. Backdating is forbidden. NCLEX exam tip: never insert content into a previous entry — always write a new dated late entry.
FACT Charting — Mnemonic for the four core principles of nursing documentation — Factual, Accurate, Complete, and Timely. Factual = observed data and quotations, not interpretations. Accurate = measured values and approved abbreviations. Complete = no missing relevant data. Timely = entered as soon after care as possible, never in advance. NCLEX exam tip: each option in a documentation question can be screened against FACT.