A nurse manager is reviewing documentation standards with a group of newly licensed nurses. Which of the following statements should the nurse manager include in the teaching?
A.
“Include the complete name of the medication morphine sulfate.”
B.
“Do not use a leading zero prior to a decimal point.”
C.
“Write the letter U when noting the dosage of insulin.”
D.
“Use the abbreviation QOD when indicating every other day.”
The Correct answer and Explanation is:
The correct answer is A. “Include the complete name of the medication morphine sulfate.”
Explanation
Documentation standards are crucial in ensuring clarity, accuracy, and safety in nursing practice. Here’s why option A is the correct choice and why the other options are incorrect:
- Complete Name of the Medication:
- A. “Include the complete name of the medication morphine sulfate.”
- This is an important standard in documentation to avoid any ambiguity or potential medication errors. Morphine sulfate should be fully written out instead of using abbreviations like “MS” or “MSO4.” This practice helps to ensure that the medication being administered is clearly identified, reducing the risk of misunderstandings or errors in medication administration.
- A. “Include the complete name of the medication morphine sulfate.”
- Leading Zero:
- B. “Do not use a leading zero prior to a decimal point.”
- This statement is incorrect because the correct standard is to use a leading zero before a decimal point (e.g., 0.5 mg) to avoid confusion with a whole number. For instance, writing “.5 mg” could be misread as “5 mg,” potentially leading to a significant dosing error. Using a leading zero clarifies the intended dose.
- B. “Do not use a leading zero prior to a decimal point.”
- Letter U for Dosage:
- C. “Write the letter U when noting the dosage of insulin.”
- The letter “U” for units is an unsafe abbreviation and is discouraged. The Joint Commission and other standard-setting organizations recommend writing out “units” to avoid confusion. Using “U” could be misread as a zero or the number “4,” which could lead to dangerous dosage errors.
- C. “Write the letter U when noting the dosage of insulin.”
- Abbreviation QOD:
- D. “Use the abbreviation QOD when indicating every other day.”
- The abbreviation “QOD” is not recommended because it can be misinterpreted. The Joint Commission advises against using “QOD” due to its potential for misreading. Instead, it is safer to write “every other day” in full to prevent any ambiguity.
- D. “Use the abbreviation QOD when indicating every other day.”
In summary, including the complete name of medications like morphine sulfate in documentation helps to avoid confusion and ensure patient safety. Other documentation practices, such as using clear language and avoiding ambiguous abbreviations, are essential to maintaining accurate and reliable patient records.