A nurse documents the following statement in a client's medical record: "2/25/09, 2235, At 2015 client awoke suddenly and complained of shortness of air. Pulse oximetry reading was 82% on room air and audible wheezes could be heard."

Question

This documentation meets which of the following documentation guidelines? Select all that apply. 1. Documentation is complete, concise, and accurate
2. Documentation is objective
3. Documentation includes the date and time of entry
4. Documentation is timely
5. Documentation is labeled late entry

Answer 1

1. Documentation is complete, concise, and accurate
2. Documentation is objective
3. Documentation includes the date and time of entry

Rationale:

Documentation is complete, concise, and accurate. Document only facts: what you can see, hear, and do. Describe what you see and do not be vague. Documentation is objective. Describe factual occurrences that you can see, hear, smell, or touch. Be objective and avoid vague statements that are subjective. Documentation includes the date and time of entry. Documenting the sequence of events and changes in patient condition is essential and should be documented as soon as possible after an observation is made or care is provided. Documentation is timely. Document as soon as possible after an observation is made or care is provided. Documentation that is done concurrently with the care provided is more likely to be accurate and complete. Deviation from the standard of care or poor documentation of care can lead to allegations of negligence. Documentation is labeled late entry. The entry was made in the client's medical record at least 2 hours after the patient complaint and should be labeled late entry. If you have forgotten to document something, or need to add important information, add the entry on the first available line and record the current date and time; label it late entry.