護理長觀察新進護理師撰寫護理紀錄。哪一項行為需要護理長立即介入糾正？
A charge nurse observes a newly licensed nurse documenting care. Which action by the new nurse requires immediate intervention by the charge nurse?
- ASigning the entry with full name and professional title以全名及專業職稱簽署紀錄
- BRecording the client's response to medication at the time of administration在給藥時記錄病人對藥物的反應
- CDocumenting that the physician made an error in the progress note✓ 正解在病程記錄中記載醫師犯錯
- DUsing approved facility abbreviations in the chart在病歷中使用機構核准的縮寫
護理紀錄（Documentation）具有法律效力，必須保持客觀、專業且事實導向。病歷是用於記錄病人狀況與護理過程，而非作為評論同事或醫師專業能力的場所。若發現醫療錯誤，應遵循機構的異常事件報告（Incident report / Adverse event report）流程，而非將主觀的批判性言論寫入病歷，這會造成嚴重的法律與專業倫理問題。
Nursing documentation has legal weight and must remain objective, professional, and fact-based. The chart is for recording client status and nursing process, not for commenting on colleagues' or physicians' professional competence. If a medical error is found, follow the facility's incident/adverse event reporting process rather than recording subjective judgmental statements in the chart, which causes serious legal and ethical issues.
美國醫院極度重視「No-Blame Culture」，發現醫療錯誤時，強制要求填寫 Incident Report（通常不放入電子病歷系統中），病歷僅記錄客觀事實（如：藥物未給予，醫師已通知），絕不會在病歷中使用指責性字眼。