The ethical principle of nonmaleficence refers to the obligation not to harm. In

The ethical principle of nonmaleficence refers to the obligation not to harm. In

The ethical principle of nonmaleficence refers to the obligation not to harm. In this scenario, allowing inaccurate charting about the patient’s orientation level to remain unaddressed harms the patient. Confusion suggests impairment in orientation, which could affect treatment decisions and discharge planning. As a nurse obligated to patient advocacy and accuracy in healthcare documents, I should speak up to address this contradiction (Umoren et al., 2021).
After rounds, I would politely approach the physician and express my concern about the discrepancy between the charting and my observed assessment. I would frame it as seeking clarification rather than accusation. If the physician confirms the intent to leave charting unchanged, I will follow the proper channels to request a chart amendment and notify the nursing supervisor. This will allow due process to confirm or rectify the record.
An organizational culture emphasizing psychological safety, accountability, and commitment to accuracy helps manage errors like inaccurate charting (Woo & Avery, 2021). Psychologically safe environments encourage speaking up about contradictions without fear of disrespect or punishment. A culture of accountability compels truth-telling and error correction rather than defensive justification. A clear commitment to accuracy as a core healthcare value reinforces vigilance in documentation, treatment decisions, and communication. With organizational values aligned around transparency and patient well-being, we can collaboratively address charting errors through supportive, corrective actions focused on quality patient care.
References
Umoren, R., Kim, S., Gray, M., Best, J. A., & Robins, L. (2021). Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study. BMJ Leader, 6(1), 15–19. https://doi.org/10.1136/leader-2020-000407
Woo, M. W. J., & Avery, M. (2021). Nurses’ experiences in voluntary error reporting: An integrative literature review. International Journal of Nursing Sciences, 8(4), 453–469. https://doi.org/10.1016/j.ijnss.2021.07.004

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