# Situation: A nurse works at the adolescent health clinic of a Rural Health Unit (RHU), which offers counseling and testing to clients aged 10 to 19 years. At 1130 the nurse reviews the entries that a colleague has made today in a 15-year-old client's record: 1. 0900 — Client states, "I have had headaches for a week." 2. 1000 — Late entry for 0930: weight 48 kg, blood pressure 110/70 mmHg. 3. 1100 — Temperature 37.9 °C (single line drawn through it, marked "error," initialed and dated), 37.2 °C. 4. 1300 — Health teaching on safe sex given; client verbalized understanding. Which entry violates documentation standards?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629664  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse works at the adolescent health clinic of a Rural Health Unit (RHU), which offers counseling and testing to clients aged 10 to 19 years.

At 1130 the nurse reviews the entries that a colleague has made today in a 15-year-old client's record:
1. 0900 — Client states, "I have had headaches for a week."
2. 1000 — Late entry for 0930: weight 48 kg, blood pressure 110/70 mmHg.
3. 1100 — Temperature 37.9 °C (single line drawn through it, marked "error," initialed and dated), 37.2 °C.
4. 1300 — Health teaching on safe sex given; client verbalized understanding.
Which entry violates documentation standards?

## 보기

1. Entry 2, because a late entry must be timed when the event occurred
2. Entry 4, because it records teaching that has not yet been given **✔ 정답**
3. Entry 3, because an error must be removed so the record stays clear
4. Entry 1, because the client's words should be summarized, not quoted

**정답: 2**

## 해설

Documentation must be timely, factual, and complete, and care is never charted in advance. Entry 4 is timed 1300 but already appears at 1130, so it records teaching that has not happened. Quoting the client, labeling a late entry with the current time, and correcting an error with a single line marked "error" and initialed all meet documentation standards.

## 심화 해설

Core documentation principle

The central rule in this item is that nursing documentation must be timely, factual, and complete — and care is never charted before it actually occurs. Entry 4 is timed 1300, yet the nurse is reviewing the record at 1130. That means the teaching on safe sex has not been delivered at the time the entry appears in the chart. Recording an intervention in advance creates a false legal record and misrepresents the care the client has actually received.

Key point! Charting ahead of time is considered falsification of the medical record, even if the nurse fully intends to perform the teaching later. The record must reflect what has already happened, not what is planned.

Why the other entries are acceptable

Entry 1 uses the client’s own words in quotation marks. Quoting the client verbatim is a standard and preferred method of documenting subjective data because it preserves the exact complaint and avoids interpretation. Entry 2 is a late entry for 0930 that was written at 1000. A late entry should be labeled as such and timed with the current time when it is being written, while clearly identifying the time the event actually occurred. Entry 3 shows an error correction using a single line drawn through the incorrect temperature, the word “error,” and the nurse’s initials and date. This is the correct method — the original entry remains legible, and the correction is transparent.

Why documentation quality matters

Accurate documentation serves multiple purposes in clinical practice. It maintains continuity of care by informing other health professionals about ongoing treatment, and it provides legal evidence of the care delivered [1]. When documentation is incomplete, untimely, or inaccurate, patient safety and legal accountability are both compromised [3]. In the community setting such as an RHU adolescent clinic, the record may be the only communication link between different providers seeing the same client across visits [1].

Common documentation errors in practice

Studies evaluating nursing documentation consistently find that standards are often not adequately met, particularly in busy clinical areas . Common problems include omissions, vague or nonspecific entries, and charting interventions before they are performed. Reflective training models have been tested as a way to improve documentation quality, suggesting that nurses benefit from structured review of their own charting habits . The systematic review of documentation evaluation methods also emphasizes that documentation quality is a multidimensional concept involving content, process, and structure .

| Documentation standard | Correct practice | Violation example |
| --- | --- | --- |
| Timeliness | Chart as soon as possible after care is given | Charting an intervention before it occurs (Entry 4) |
| Late entry | Label as late entry; write current time; note actual event time | Backdating the entry to the event time without labeling |
| Error correction | Single line through error; write “error”; initial and date | Erasing, using correction fluid, or scribbling out completely |
| Subjective data | Quote the client’s exact words in quotation marks | Paraphrasing in a way that changes the meaning |

Watch out! In licensure exams, the most dangerous documentation error is usually the one that creates a false record — either by charting in advance or by altering an entry to hide a mistake. Entry 4 is the only option that records something that has not yet happened, making it the clear violation of documentation standards.References (research sources)

- [1]Documentation in nursing practice.Research articleOwen K (2005) · DOI: 10.7748/ns2005.04.19.32.48.c3846

- [3]Exploring multilevel determinants of nursing documentation quality in suicide care: A qualitative Study in Iranian hospitals.Research articleYusefi AR, Atashbahar O, Kheirkhah Vakilabad AA, Askarpour H, Bahmeai J. (2026) · DOI: 10.1371/journal.pone.0356460

## 임상 시나리오

Documentation StandardsNever chart care before it occurs
Nursing documentation must be timely, factual, and complete. Recording an intervention before it happens, such as a 1300 teaching entry present at 1130, is falsification of the record.

A late entry should be labeled as such and timed with the current time when written, while clearly identifying when the event actually occurred.

To correct an error, draw a single line through it, write "error", and add initials and date. The original entry must remain legible.

CautionCharting ahead of time creates a false legal record, even if the nurse intends to perform the care later. The record must reflect only what has already happened.

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## 핵심 개념

- **Late entry** — A chart entry made after the event; labeled as late, timed with the current writing time, and identifies when the event occurred.
- **Falsification of record** — Recording care or interventions before they actually happen, which misrepresents the care provided and creates a false legal record.
- **Error correction** — Drawing a single line through the error, writing 'error,' and initialing and dating; the original entry remains legible.
- **Verbatim quotation** — Documenting the client's exact words in quotation marks to preserve subjective complaints without interpretation.

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