Which of the following is a correct documentation made by the nurse assistant?
A)In bed. Complains of headache. T 98.4 orally, radial pulse 72 and regular, respirations 18 and unlabored. BP 134/84 left arm lying down. Alice Jones, RN, notified of resident complaint and vital signs. Ann Adams, CNA
B)Complains of abdominal pain after eating hamburger, fries, and milkshake during lunch. Vital signs taken in normal readings. Referred to nurse-on-duty. Monitored for further abdominal pain. Vicky Tomms, CNA
C)Appears depressed after visited by relatives probably due to bad news. Will follow-up later. Mary Atkins, CNA
D)Warm to touch. Applied cold compress on forehead. Referred to physician for prn medications. Temperature above normal. Jane Craig, CNA

Question

Quizplus · Accepted Answer

This option is the correct answer because it follows all the rules for recording:
-Record only what you observed and did yourself.
-Never chart a procedure or treatment until after it is completed.
-Be accurate, concise, and factual; do not record judgments or interpretations.
-Record in a logical and sequential manner.
-Be descriptive. Avoid terms with more than one meaning.
-Record any changes from normal or changes in the client's condition. Also record that you informed the nurse (include the nurse's name), what you told the nurse, and the time you made the report.

Which of the Following Is a Correct Documentation Made by the Nurse