護理長觀察到一位新進護理師正在紀錄一項由護理助理執行過的醫療程序，護理長應採取何種行動？
A charge nurse observes a newly hired RN documenting a procedure that was performed by a nursing assistant. Which action should the charge nurse take?
- ASpeak with the RN privately to discuss the legal implications of documentation✓ 正解私下與RN溝通，討論紀錄的法律意義
- BInstruct the RN to sign the note as a co-signer指示RN以共同簽署者身分簽名
- CIgnore the observation as the task is documented忽略此次觀察，因為任務已有紀錄
- DReport the RN to the state board of nursing immediately立即向護理師執照委員會舉報該RN
護理紀錄必須具備法律效力與真實性，即「誰執行，誰紀錄」。由未親自執行醫療程序的人員進行紀錄，不僅違反護理專業倫理，更涉及法律造假（Falsification of medical records）。護理長作為管理階層，首要職責是教育與糾正，應私下與該護理師溝通，釐清法規與專業責任，而非直接懲處或忽略，以確保單位照護品質與法律安全。
Documentation must accurately reflect who performed the procedure to maintain legal validity and ethical standards. The charge nurse should privately counsel the RN about the legal implications of falsifying records, as co-signing or ignoring the error compromises patient safety and professional integrity, while immediate reporting to the board is excessive for a first-time educational opportunity.
美國醫院對於護理紀錄（Documentation）的法律嚴謹度極高。任何代簽或虛假紀錄都可能導致執照吊銷（License revocation），護理主管對此類違規通常採取零容忍態度，但初期仍會透過正式面談紀錄（Counseling）來進行教育。