A nurse documents the following in a patient's medical record: "2/1/__, 1500. Patient appears weak and faint. Patient's skin is moist and cool, vomited bright red blood with clots. Health care provider notified and order received to give 2 u of packed red blood cells if stat Hgb is

Question

A nurse documents the following in a patient's medical record: "2/1/__, 1500. Patient appears weak and faint. Patient's skin is moist and cool, vomited bright red blood with clots. Health care provider notified and order received to give 2 u of packed red blood cells if stat Hgb is < 8.0. Pain medication will be given." This documentation meets which documentation principle?

Quizplus · Accepted Answer

The documentation in the patient's medical record reflects the principle of documenting changes in patient condition. The nurse has recorded the patient's symptoms and the healthcare provider's order for a blood transfusion in response to the patient's low hemoglobin level. The note is objective and does not document procedures in advance, and although there are some abbreviations used, they are approved and easily understood. However, the main focus of the documentation is on the change in the patient's condition, which is a key aspect of nursing documentation.

A Nurse Documents the Following in a Patient's Medical Record