Nursing assistive personnel (NAP) finds a patient on the floor 30 minutes after the patient ambulated with physical therapy. What information should be charted by the NAP on the inci-dent report?
a. "Patient fell out of bed and landed on the floor.".
b. "Patient found on floor. Upper side rails up. Bed in low position.".
c. "Patient got dizzy and fell although am-bulated with physical therapy earlier.".
d. "Patient unfortunately slipped and fell.".
B
Documentation should state facts: "Patient found on floor. Upper side rails up. Bed in low posi-tion.". Only objective data with no interpretation can be documented by the NAP. The NAP does not evaluate the situation. Words such as "unfortunately" are never used in documentation. The NAP found the patient on the floor and did not see the patient slip and fall.
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