The nurse makes a late entry in a client's record.Which of the following is the best example of how to document this type of situation?
A) "2:45 PM-ASA gr X given for temperature of 38.1° C."
B) "8:30 AM-Client received Percodan (1 tablet)PO an hour before going to radiology."
C) "12:15 PM-I gave the client morphine 10 mg IM at 11:10 AM but did not document it then."
D) "8:30 PM-Abdominal dressing change at 7:30 PM.No s/s of infection,and wound edges approximating well."

Question

Quizplus · Accepted Answer

This is the best example of a late entry.The time (2:45 PM)is indicated along with the action and an objective observation.This notation (8:30 AM)is not complete.It does not indicate why the Percodan was given.What was the client's level of pain? Where was the pain located? The nurse does not need to document about herself;only the client.In this option (12:15 PM),the nurse does not indicate why the morphine was given (client's level of pain? location of pain?).This entry (8:30 PM)is not complete.It does not state the size of the wound,type of dressing used,or the client's tolerance of the procedure.

The Nurse Makes a Late Entry in a Client's Record