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Observing & Reporting Changes in Condition

When charting, the assistant did not see whether a resident ate the snack left at bedside. What is the honest and correct approach?

  • A.Chart only what was actually observed and tell the nurse it was not seen
  • B.Chart that the snack was eaten to complete the form
  • C.Guess an amount based on what she usually eats
  • D.Copy a coworker's note about a different resident
Correct answer

A. Chart only what was actually observed and tell the nurse it was not seen

Why

Documentation must reflect only what the assistant personally observed or measured. Guessing, assuming, or copying another note creates false records and can harm care decisions.

Content outline: Basic Nursing Skills - Observing and Reporting Changes · From the Basic Nursing Skills practice bank (BN-073).

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