Which entry will require follow-up by the nurse manager?
0800 Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. Call bell within reach. Bed monitor on.
-------------------Jane More, RN
0810 Notified primary care provider of patient's status. New orders received. -------------------Jane More, RN
0815 Portable x-ray of L hip taken in room. States, "I feel fine." -------------------Jane More, RN
0830 Incident report completed and placed on chart.
-------------------Jane More, RN
a. 0800
b. 0810
c. 0815
d. 0830
ANS: D
Do not include any reference to an incident in the medical record; therefore, the nurse manager must follow up. A notation about an incident report in a patient's medical record makes it easier for a lawyer to argue that the reference makes the incident report part of the medical record and therefore subject to attorney review. When an incident occurs, document an objective description of what happened, what you observed, and the follow-up actions taken, including notification of the patient's health care provider in the patient's medical record. Remember to evaluate and document the patient's response to the incident.
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