When documenting in the patient's chart, the nurse should:

Explanation

•The patient's chart is a legal document, so the nurse should use a pen with all documentation.

•Each entry should be signed with the nurse's full name and title.

•The nurse should not leave blank lines in the patient's medical record as this could allow other healthcare workers to make additions.

•A single line through an entry that is incorrect is acceptable.

•It is illegal to erase errors in a legal document such as a medical record. Wite-Out or blacking out the writing is not permitted.

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