護理師發現同事在執行程序前就已完成紀錄，護理師應優先採取何種措施？
A nurse notices a colleague documenting a procedure on a client before performing it. What is the priority action?
- ATalk to the colleague privately about the practice✓ 正解私下與同事討論此做法
- BReport the colleague to the ethics committee向倫理委員會舉報該同事
- CIgnore it since no patient was harmed忽略此事，因為沒有病人受到傷害
- DComplete an incident report immediately立即完成事件報告
此為欺詐記錄（charting ahead）行為，屬於嚴重的護理道德問題。在發現問題初期，應採取「教導與預防」原則，先私下勸導並教育同事此行為的風險與後果。若勸導無效或事件涉及嚴重醫療欺詐，再行通報主管。直接跳過溝通而進行控告或紀錄並不符合專業人際溝通原則。
This represents fraudulent documentation ('charting ahead') and constitutes a serious nursing ethical issue. When this problem is first identified, the principle of education and prevention should be applied, with the colleague being privately counseled and educated about the risks and consequences of this practice. If counseling is ineffective or the event involves serious medical fraud, escalation to a supervisor is appropriate. Bypassing direct communication and immediately filing a complaint or report does not align with the principles of professional interpersonal communication.
台美對醫事記錄的嚴肅性一致，但對於非惡意造假的預防教育，台灣更傾向於內部溝通解決。