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Reporting, Documentation & The Care Plan

Why must charting be done in ink and without correction fluid?

  • A.Ink dries faster than pencil on most chart forms
  • B.Ink is less expensive for the facility to supply
  • C.Pencil is harder for nurses to read than ink is
  • D.The chart is a legal record and entries must be permanent and unchanged
Correct answer

D. The chart is a legal record and entries must be permanent and unchanged

Why

The medical record is a legal document, so entries must be permanent and any change must remain visible. Pencil can be erased and correction fluid can hide entries, which destroys the record's legal value.

Content outline: Role of the Nurse Aide - Documentation: Legal Record · From the Role of the Nurse Aide practice bank (RA-103).

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