As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding nonpharmacological measures. What action should you take first?

• A. Give praise for correctly charting the dose and time and discuss the deficits in charting.
• B. Make a note in the nurse's file and continue to observe clinical performance.
• C. Quiz the nurse about knowledge of pain management and pharmacology.
• D. Refer the new nurse to the in-service education department.

Answer: (A)

Focusing on constructive feedback right away is the key. When supervising a newly graduated RN, recognize what was done correctly to reinforce good practice, then address gaps that could affect patient care. The chart shows accurate documentation of the medication dose and time, which demonstrates safe administration and attention to pharmacologic details. The missing documentation of nonpharmacologic pain management measures is a real gap because these interventions, like repositioning, heat/cold, distraction techniques, or relaxation methods, are part of comprehensive pain care and should be recorded so the entire plan is visible and so future care teams understand what was tried and its effectiveness.

The first step is to praise the correct charting and have a focused, supportive discussion about documenting nonpharmacologic measures. Provide clear guidance on what to document (type of intervention, when it was used, duration, patient response, and outcome) and why it matters for ongoing assessment and continuity of care. This approach reinforces good habits, builds learning, and sets a standard for thorough documentation.

Other approaches—quizzing on knowledge, filing a formal note, or referring to in-service education as the immediate next step, or merely observing without feedback—don’t address the specific documentation gap in the moment and delay improvement.