A nurse has provided care to a patient.Which entry should the nurse document in the patient's record?
A)"Patient seems to be in pain and states,'I feel uncomfortable.'"
B)"Status unchanged,doing well."
C)"Left abdominal incision 5 cm in length without redness,drainage,or edema."
D)"Patient is hard to care for and refuses all treatments and medications.Family present."

Question

Quizplus · Accepted Answer

Use of exact measurements establishes accuracy.Charting that an abdominal wound is "5 cm in length without redness,drainage,or edema" is more descriptive than "Large wound healing well." The patient's record should include objective data to support subjective data,so that charting is as descriptive as possible.Vague terms such as appears,seems,or apparently convey opinion rather than fact,do not accurately communicate facts,and do not inform another caregiver of details regarding behaviours exhibited by the patient.The nurse should avoid using generalized,uninformative phrases such as "Status unchanged" or "Had a good day." It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions.A statement such as "Patient is hard to care for" is a personal opinion and should be avoided.It is also a critical comment that can be used as evidence of nonprofessional behaviour or poor quality of care.The only statement to chart would be "Refuses all treatments and medications."

A Nurse Has Provided Care to a Patient