At 9:15 AM the nurse repeatedly instructs the patient to remain in bed. At 9:30 the nurse enters the patient's room, finds the patient on the floor, and hears the patient say, "I need pain medi-cine."
Which should the nurse do to document this event? a. Label the late entry using the time of 9:15 AM
b. Enclose the patient statement within quo-tations
c. Document completion of an incident re-port
d. Record medication before its administra-tion
B
The nurse encloses patient statements in quotations to indicate the patient's precise statement. Subjective information is documented using the patient's words in quotes. The nurse should document instructions given at 9:15 and verify any indications of patient comprehension. A second entry noted at 9:30 documents finding patient on floor.
Completion of an incidence report is not documented in the patient record since it is an internal evaluation report. Administration of medication is only documented after it occurs to make sure that the documentation is accurate in terms of time and patient response.
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