# Situation: A 34-year-old man with a closed fracture of the left femur is in skeletal traction on the orthopedic ward, 1 day after admission. The ward keeps a Kardex for each client and writes its nursing notes on paper. At 13:00 the nurse realizes that the entry "10:00 Pin sites clean and dry, no drainage" in this client's notes belongs to the client in the next bed, whose pin sites the nurse checked at 10:00 and found as written. The notes are on paper. What should the nurse do?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630458  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 34-year-old man with a closed fracture of the left femur is in skeletal traction on the orthopedic ward, 1 day after admission. The ward keeps a Kardex for each client and writes its nursing notes on paper.

At 13:00 the nurse realizes that the entry "10:00 Pin sites clean and dry, no drainage" in this client's notes belongs to the client in the next bed, whose pin sites the nurse checked at 10:00 and found as written. The notes are on paper. What should the nurse do?

## 보기

1. Draw one line through it, "mistaken entry," date, time and initials; chart it for the other client at 10:00
2. Cover it with correction tape, write "mistaken entry," date, time and initials; chart it for the other client as a late entry
3. Draw one line through it, "mistaken entry," date, time and initials; chart it for the other client as a late entry **✔ 정답**
4. Draw one line through it, "mistaken entry" and her initials only; chart it for the other client as a late entry

**정답: 3**

## 해설

Two rules apply. The wrong entry is corrected with a single line so it stays readable, labeled "mistaken entry" (or "error"), with the date, time, and initials. The finding itself was real, so it is recorded in the correct client's notes as a late entry showing the current time and the 10:00 time of the check.

## 심화 해설

Two separate problems to fix
The nurse wrote a real finding in the wrong client's notes. Two rules apply: the wrong entry is corrected so it remains readable and traceable, and the valid finding is recorded in the correct client's notes as a late entry. Option 3 does both correctly: a single line through the entry, the words mistaken entry, the date, time, and initials, and a late entry in the other client's chart.

Correcting the wrong entry
On a paper record, an error is corrected with a single line drawn through the text so that it can still be read. The nurse writes mistaken entry (or error, according to policy) with the date, time, and initials of the correction. The original must never be erased, scribbled over, or covered with correction tape or fluid, because the record must show what was written and when it was changed. Hiding an entry can look like falsification of a legal document.

Recording the finding for the correct client
The pin-site check was real: the nurse checked the other client's pin sites at 10:00 and found them clean and dry. That finding belongs in the other client's notes. Because it is being written at 13:00, it is labeled a late entry, showing the current date and time and stating that the assessment was made at 10:00. Writing it as though it were charted at 10:00 would misrepresent when the note was made.

| Option | Correction | Late entry | Verdict |
| --- | --- | --- | --- |
| 1 | Correct | Charted as if at 10:00 | Wrong |
| 2 | Correction tape hides the original | Correct | Wrong |
| 3 | Single line, label, date, time, initials | Labeled late entry | Correct |
| 4 | Initials only, no date and time | Correct | Wrong |

Watch out! Each wrong option differs from the right one by a single detail. Read every element: how the original is crossed out, what is written beside it, and how the time of the new entry is shown.

Exam takeaway
Key point! Correct errors with one line, keep the original readable, add mistaken entry with date, time, and initials, and chart valid findings for the right client as a late entry.

## 임상 시나리오

Correcting a Charting ErrorWrong client, real finding
The 10:00 pin-site note was written in the wrong client's chart, but the finding was real.

Correct it with a single line, mistaken entry, and the date, time, and initials; the original stays readable.

Chart the finding for the right client as a late entry at 13:00, noting the check was made at 10:00.

CautionNever use correction tape, erase, or chart a late note as if it were written at the earlier time.

## 핵심 개념

- **Late entry** — A note added after the usual time, labeled with the current date and time and the time of the original event.
- **Mistaken entry** — The label written beside a crossed-out charting error, with the date, time, and initials.
- **Falsification** — Altering or hiding information in a legal record, which is a serious legal and ethical violation.
- **Pin site care** — Assessment and cleaning of the skin where traction pins enter the bone.

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