A nurse documents the following in a client's medical record: "2/1/09, 1500, Client appears weak and faint. Client's skin is moist and cool, vomited bright red blood with clots

Question

Health care provider notified and order received to give 2 u of packed red blood cells if stat Hgb is < 8.0.". This is an example of documentation that reflects: 1. A change in a client's condition.
2. Appropriate use of abbreviations.
3. Objective data only.
4. Documentation of a procedure in advance.

Answer 1

A change in a client's condition.

Rationale: In general, employers, and state, federal, and professional standards require documentation to include initial and ongoing assessments, any change in the patient's condition, therapies given and patient response, patient teaching, and relevant statements by the client. The Joint Commission has designated the inappropriateness of "u" as an abbreviation. "U" should be written out as "unit(s)". If unsure, the abbreviation is correct, spell out the word; "<" can be misinterpreted, so it should be spelled out as "less than.". Be objective and avoid vague statements that are subjective. Describe factual occurrences that can be seen, heard, smelled, or touched. The use of the word "appears" is subjective and could be manipulated later should the treatment or judgment be challenged. The client record is a legal document, so the nurse should never document procedures or medication administration in advance. The nurse has documented the order received; the documentation does not say the packed red blood cells were infused at a later time.