A nurse documents this statement in a patient's medical record: "2/25/--, 2235. At 2015 patient awoke suddenly and complained of shortness of air. Pulse oximetry reading was 82% on room air and audible wheezes could be heard
" This documentation meets which documentation guidelines? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Documentation is timely
2. Documentation is concise
3. Documentation is objective
4. Documentation includes date and time of entry
5. Documentation is complete and accurate
2,3,4,5
Rationale 1: The nurse should document as soon as possible after an observation is made or care is provided. The entry was made in the patient's medical record at least 2 hours after the patient complaint and should be labeled late entry.
Rationale 2: This entry describes the situation fully but is concise.
Rationale 3: The nurse describes factual events that can be seen, heard, smelled, or touched. It is important to be objective and avoid vague statements that are subjective.
Rationale 4: Both the date and the time of the entry are documented.
Rationale 5: The nurse should document only facts: what he or she can see, hear, and do.
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