— 照護管理 · MEDIUM · MCQ —
護理師在病人的病歷中進行書寫，下列哪項紀錄在法律上是適當的？
A nurse is documenting in a client's chart. Which entry is legally appropriate?
- ANurse made a mistake while administering medication護理師在給藥時犯了錯。
- BClient reports 'I feel like my heart is racing' at 14:00✓ 正解客戶於14:00表示『我覺得我的心跳很快』。
- CClient seems to be depressed today客戶今天看起來很沮喪。
- DPhysician is incompetent and did not check the labs醫師無能，且未檢查檢驗報告。
— Explanation · 中文詳解 —
護理紀錄必須客觀、精確且不含主觀批判。正確的紀錄應包含時間與病人自述內容（引號內）。選項 C 過於主觀且無客觀表現；選項 A 應說明補救措施而非直接承認錯誤（應由異常事件報告處理）；選項 D 包含批判性言論，在法律文件中是不可接受的，可能引發法律糾紛。
Legal nursing documentation must be objective, precise, and free of subjective interpretations or personal criticisms. Using direct quotes from the client along with specific timestamps provides factual evidence of the client's condition, whereas subjective judgments or admissions of error without context are inappropriate for medical records.
✦ 台美臨床差異
台美護理師在書寫紀錄時，皆極度強調避免主觀字眼，因為病歷在法律上是重要證據。