A nurse completes an occurrence report. Which is the best way for the nurse to document this occurrence?
a. "Patient found lying on right side on floor. No noted injuries, patient stated, ‘I slipped on a wet spot on the floor. I don't think I am injured.'"
b. "Patient slipped on a wet spot on the floor. No noted injuries, physician notified."
c. "Patient in too much of a hurry and was walking too fast and fell. Was not injured. Patient instructed to slow down and not be in such a hurry. Health care provider notified."
d. "Patient fell while going outside to smoke. Patient denied any injuries. Health care provider notified. Patient counseled."
A
Objectively record the details of the event and any statements the patient makes. An example is as follows: "Patient found lying on floor on right side. Abrasion on right forehead. Patient stated, ‘I fell and hit my head.'" Patient slipped on wet spot and patient fell while going outside should not be charted unless the nurse actually observed the event; otherwise, chart what found: Patient lying on floor. Patient in too much of a hurry includes subjective assumptions and statements; assigning blame or fault is inappropriate when completing the report.
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