A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?
a. "Patient seems to be in pain and states, ‘I feel uncomfortable.'"
b. Status unchanged, doing well
c. Left abdominal incision 1 inch in length without redness, drainage, or edema
d. Patient is hard to care for and refuses all treatments and medications. Family present.
C
Use of exact measurements establishes accuracy. Charting that an abdominal wound is "5 cm in length without redness, drainage, or edema" is more descriptive than "large wound healing well." Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as "status unchanged" or "had a good day." It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. "Patient is hard to care for" is a personal opinion and should be avoided. It is also a critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, "Refuses all treatments and medications."
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