A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation?

Question

A nurse is documenting notes in the client's electronic record after making rounds on assigned clients.  Which entry is an appropriate documentation?

Quizplus · Accepted Answer

The electronic record is a legal document and should contain factual, descriptive, objective information that the nurse sees, feels, hears, and smells. It should be the result of direct observation and measurement. "Inspiratory wheezes heard in bilateral lung fields" best fits these criteria. The nurse should avoid vague terms such as "appears," "seems," and "normal." These words suggest that the nurse is stating an opinion and do not accurately communicate facts or provide information on behaviors exhibited by the client. The nurse should provide exact measurements, establish accuracy, and not provide opinions or assumptions. (Option A) The nurse should not use the word "appears" as it is too vague. "Eyes closed" is a factual observation. A more accurate entry would be, "Client lying in bed with eyes closed. Respirations even and unlabored." (Option B) It is a good practice to document client quotes. However, in this case, the nurse should have elicited more information from the client, such as a pain scale, and then documented the analgesic the client was given. (Option D) This documentation would be more descriptive if it listed how much urine, its color and clarity, and if an odor was present. Educational objective: Nursing documentation should be factual, descriptive, and contain objective information that the nurse sees, hears, feels, or smells. It must include direct observation and measurement.

A Nurse Is Documenting Notes in the Client's Electronic Record