— 照護管理 · MEDIUM · MCQ —
護理長發現新進護理師記錄了一項未執行的處置。護理長應採取什麼行動？
A charge nurse observes a newly licensed nurse documenting a procedure that was not performed. Which action should the charge nurse take?
- AReport the nurse to the state nursing board immediately立即將該護理師報告至州護理委員會
- BDiscuss the incident with the new nurse privately✓ 正解私下與新進護理師討論此事件
- CCorrect the documentation in the electronic health record在電子病歷中更正紀錄
- DIgnore the action as long as no harm occurred只要未造成傷害便忽略此行為
— Explanation · 中文詳解 —
護理紀錄造假（Documentation falsification）是嚴重的職業道德缺失。護理長應先私下與該護理師面談，了解原因並提供教育，確保其明白護理紀錄的法律效力。直接上報委員會需依單位流程，而忽略或擅自修改皆不符合專業管理原則。
Documentation falsification is a serious ethical and legal violation that requires immediate internal intervention. The charge nurse should discuss the incident privately with the newly licensed nurse to address the behavior, ensure understanding of professional standards, and determine the appropriate corrective actions before considering further reporting.
✦ 台美臨床差異
美國非常重視 documentation 法律規範，台灣對於紀錄造假多採單位行政懲處與再教育，嚴重者才會涉及法律訴訟。