According to documentation guidelines the most appropriate notation is
A)"1230 hours: Patient's vital signs taken."
B)"0700 hours: Patient drank adequate amount of fluids."
C)"0900 hours: Morphine given for lower abdominal pain."
D)"0830 hours: Increased IV fluid rate to 100 mL per hour."

Question

Quizplus · Accepted Answer

Information within a recorded entry must be complete,containing appropriate and essential information.The notation "0830 hours: Increased IV fluid rate to 100 mL per hour" provides the time and action taken by the nurse,including the reason for doing so.The entry "1230 hours: Patient's vital signs taken" does not indicate what the patient's vital signs were.The entry "0700 hours: Patient drank adequate amount of fluids" does not provide the specific amount that the patient drank.Stating "adequate" is subjective,not objective.The notation "0900 hours: Morphine given for lower abdominal pain" does not indicate how the patient describes his or her pain or rates it on a pain scale for comparison later.It also does not indicate whether the patient's pain was in the lower left or lower right quadrant,or both.

According to Documentation Guidelines the Most Appropriate Notation Is