You chart the following: 7/16/00 0900 C/o sharp, constant pain in L hip, requesting pain medication. BP 98/50, P 62, R 10. Oriented ×3. Responds to verbal stimuli but easily returns to sleep
Need to wait for pain medicine explained due to low BP & resp. and length of time since last injection 3 hours (order is for q4 hours). Will reassess in 15 minutes. What type of documentation is this?
1. an explanation of why medication is withheld
2. admit note
3. observation of psychosocial status
4. client teaching note
ANS: 1
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