A nurse is frustrated about the lack of staffing for the shift. When one of the patients fell and broke a hip, the nurse documented the incident in the patient's chart. Which entry is the best way that the nurse should document what happened?
a. "Patient stated that fell while going to the bathroom. Physician notified."
b. "Nobody available to answer call bell; patient got up on own and fell."
c. "Patient fell because of unsafe staffing levels on unit."
d. "Patient waited as long as possible but nobody there to help and fell."
A
Charting should be factual. Patient stated that fell is the most factual. Do not write retaliatory or critical comments about patient or care by other health care professionals. Statements that are retaliatory or critical can be used as evidence for nonprofessional behavior or poor quality of care. Nobody available to answer call bell, fell because of unsafe staffing levels, or nobody to help are all retaliatory or critical comments and should not be used.
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