Patients on the unit have their vital signs taken routinely at 0800, 1200, 1600, and 2000 . At 1000, a patient complains of feeling "light-headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual

Question

Within 15 minutes, the patient says that he feels better. The nurse rechecks the blood pressure and finds that it is now back to normal. How should the nurse handle documentation for this episode? a. Document the 1000 vital signs in the graphic record only.
b. Not report the incident because it was a transient episode.
c. Document the vital signs in the graphic and progress record.
d. Document the vital signs as 12 o'clock signs.

Answer 1

C
When documenting a significant change on a flow sheet, you describe the change, including the patient response to nursing interventions, in the progress notes. For example, if a patient's blood pressure becomes dangerously low, record the blood pressure in the progress notes, as well as relevant assessment such as pallor and dizziness and any interventions performed to raise the blood pressure. Common issues in malpractice caused by inadequate or incorrect documentation include failing to give a report or giving an incomplete report to an oncoming shift and failing to document the correct time of events.