The nurse records this entry in a patient's progress notes:

Question

Patient escorted to unit by ER nurse at 2130. Patient's clothing was dirty. In interview room, patient sat with hands over face, sobbing softly. Did not acknowledge nurse or reply to questions. After several minutes, abruptly arose, ran to window, and pounded. Shouted repeatedly, "Let me out of here." Verbal intervention unsuccessful. Order for stat dose 2 mg haloperidol PO obtained; medication administered at 2150. By 2215, patient stopped shouting and returned to sit wordlessly in chair. Patient placed on one-to-one observation.
How should this documentation be evaluated?

a. Uses unapproved abbreviations
b. Contains subjective material
c. Too brief to be of value
d. Excessively wordy
e. Meets standards

Answer 1

ANS: E
This narrative note describes patient appearance, behavior, and conversation. It mentions that less-restrictive measures were attempted before administering medication and documents patient response to medication. This note would probably meet standards. A complete nursing assessment would be in order as soon as the patient is able to participate. Subjective material is absent from the note. Abbreviations are acceptable.