Upon noticing a discrepancy in wound care documentation, what should the nurse’s initial action be?

The nurse's initial action upon noticing a discrepancy in wound care documentation should be to consult with the practical nurse (PN) about the discrepancy. This approach fosters collaboration and ensures that the nursing team is aligned on the patient's care. It is essential to clarify and verify the documentation with the individual who may have been involved in the care process to understand the context and accuracy of the records.

Engaging with the PN allows for addressing the issue directly and provides an opportunity to rectify any misunderstandings or errors in the documentation before taking further actions. This step emphasizes the importance of communication within the healthcare team, ensuring that patient safety and care quality are prioritized.

Other actions, such as changing the dressing or filing an incident report, may be necessary later but should follow the consultation to understand the situation fully. Informing the healthcare provider might also occur at some point, but the immediate step should involve resolving the discrepancy with the PN to inform the next course of action effectively.