Documentation, Records, and Reporting Obligations
This domain tests the nurse's duty to create an accurate clinical record and to make required external reports. Documentation standards come from KRS Chapter 314, Board practice regulations, and facility policy; reporting duties come from statutes such as KRS 620.030, KRS 209.030, and KRS 214.010.
Documentation
- Record assessments, interventions, patient responses, education, notifications, consent, and errors with date, time, and authentication.
- Entries must be objective, factual, timely, and complete. Avoid speculation, opinions, and vague phrases such as "patient fine."
- Late entries must be labeled as late and follow policy. Never alter, delete, or backdate another clinician's entry; correct errors with a dated, timed, initialed correction per policy.
- Incident reports are risk-management documents. Document the clinical facts and care in the medical record; do not copy the incident report into the chart.
Reporting obligations
- Child abuse or neglect must be reported under KRS 620.030 to the Cabinet for Health and Family Services or law enforcement.
- Adult abuse, neglect, or exploitation must be reported under KRS 209.030.
- Reportable communicable diseases must be reported to the local health department under KRS 214.010 and 902 KAR 2:020.
- Report unsafe practice or impairment as required by Board rules and facility policy; report sentinel events through the facility's safety system.
Worked example. A nurse gives the wrong dose of insulin. She assesses the patient, notifies the provider, monitors glucose, documents the drug, dose, time, patient response, and provider notification, and completes an incident report. The clinical record tells the care story; the incident report supports risk review and is not substituted for charting.
Traps. Charting conclusions without supporting data; backdating an entry; reporting abuse only to a supervisor; omitting a reportable disease because treatment has already started.