Two days ago a patient fell while jogging and hurt his left foot. Since then his left foot has remained painful. Which of the following chart entries is documented correctly?
a. Mass the size of an egg on the left ankle. c. Occasionally takes ibuprofen for pain.
b. Pain in left foot appears to be worse today. d. Left foot with 2+ nonpitting edema.
D
Use specific measurements (e.g., "mass 3 cm ? 5 cm") rather than relative statements about findings (e.g., "mass the size of an egg"). Avoid using judgmental language such as "appears to be good, bad, better, or worse." The time intervals should be stated precisely (e.g., "every 4 hours," "bid," instead of "occasionally," "seldom." Left foot with 2+ nonpitting edema is the correct documentation
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