A clinic nurse is documenting in a patient medical record about the pain that brought the patient to seek medical attention. The best description is:
A) "Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch."
B) "Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch."
C) "Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse."
D) "Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids."

Question

Quizplus · Accepted Answer

When documenting a sign or symptom, the nurse should include the quality (levels 7 to 8), chronology (after lunch, last 3 hours), and aggravating or alleviating factors, as well as associated symptoms.

A Clinic Nurse Is Documenting in a Patient Medical Record