The nurse successfully transfers a patient from the bed to the chair and back. What information is most vital for the nurse to include in the progress notes?
a. The visitors involved in assisting the pa-tient to transfer
b. Home care instructions for the patient about transferring
c. The patient's blood pressure before and after each transfer
d. A description of the patient's response to each transfer
D
The nurse documents the patient's response to each transfer in objective terms to record the events and subjective terms to relate the patient's response to communicate information. Factors to consider in the documentation are breathing difficulties, dizziness, balance, muscle strength, patient complaints, type and degree of assistance the patient requires to transfer, and progress toward goals and outcomes. To prevent patient and visitor injuries, visitors should not assist the patient to transfer. Home care instructions are suitable before discharge. Patient blood pressure is recorded on the graphic flow or vital signs sheet.
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a. true b. false
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