Which entry by the nurse demonstrates the most accurate and safe documentation of patient care?
A) "Sm. amt. of emesis."
B) "150 mL of cloudy dark yellow urine."
C) "Had a good day."
D) "Looks bad."

Question

Quizplus · Accepted Answer

150 mL of cloudy dark yellow urine is the best.The use of precise measurements makes documentation more accurate.To avoid misunderstandings and promote patient safety,write out any abbreviations that are possibly confusing.Avoid using generalized,empty phrases,such as "had a good day." Be objective and factual; do not use "looks bad" because it is vague and too general.

Which Entry by the Nurse Demonstrates the Most Accurate and Safe