The nurse is caring for a hospitalized client. Which are the best examples of narrative documentation to provide legal malpractice protection for the nurse after an adverse event? Select all that apply.

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Documentation should be clear, concise, and accurate to be credible, which includes being timely, truthful, and appropriate. When charting a symptom or situation, the nurse should chart the interventions taken and the client response. An adverse event is an unusual occurrence, accident, or injury unrelated to the client's underlying condition. Adverse events must be acknowledged and documented in the chart. It is essential for the nurse to note the actions taken in response to the event (eg, client teaching, safety precautions) and the time frame in which they were performed. Documenting the key, pertinent negatives indicating that no client harm resulted and the appropriate interventions implemented to rectify or reduce harm will minimize nursing liability. If an incident report is also required, it is separate from the medical record and should never be mentioned in the client's chart. (Option A) Lack of a verbalized symptom does not ensure that no injury was sustained. In addition, documentation should be objective and not contain opinions. (Option B) A generic notation of "continue to monitor" is meaningless; the nurse should monitor all clients regardless of the situation. (Option E) "Suspicious" is subjective wording; the nurse should document exactly which actions appeared suspicious (eg, rapidly hides package every time nurse enters room; will not let nurse see package). Educational objective: After an adverse event, the nurse should document objective, specific assessments and interventions. These include signs/symptoms indicating a lack of client harm and any corrective actions taken.

The Nurse Is Caring for a Hospitalized Client