A nurse documents the following in a patient's medical record: "2/1/__, 1500. Patient appears weak and faint. Patient's skin is moist and cool, vomited bright red blood with clots
Health care provider notified and order received to give 2 u of packed red blood cells if stat Hgb is < 8.0. Pain medication will be given." This documentation meets which documentation principle? 1. Document objectively.
2. Do not document procedures in advance.
3. Use approved abbreviations.
4. Document changes in patient condition.
4
Rationale 1: Documentation should be objective and avoid vague statements that are subjective. Only factual occurrences that can be seen, heard, smelled, or touched should be described. The use of the word "appears" is subjective and could be manipulated later should the treatment or judgment be challenged.
Rationale 2: The nurse has documented that pain medication will be given. This is documenting in advance.
Rationale 3: The Joint Commission has designated the inappropriateness of "u" as an abbreviation. "U" should be written out as "unit(s)." If unsure whether the abbreviation is correct, the nurse should spell out the word; "<" can be misinterpreted, so it should be spelled out as "less than."
Rationale 4: In general, employers as well as 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 patient.
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