Which of the following chart entries represents a pitfall in documentation?
a. Restless and combative; SaO2 87%
b. Patient demanding and difficult to please
c. Discovered in bathroom; instructed to ask for assistance before ambulating
d. Three-centimeter area of serosanguineous drainage noted on the dressing to the left hip
ANS: B
A
"Restless and combative; SaO2 87%" is an acceptable chart entry.
B
The chart entry is subjective and nonspecific. It also contains judgments about the patient which could be interpreted as bias.
C
"Discovered in bathroom; instructed to ask for assistance before ambulating" is an acceptable chart entry; it is accurate and concise.
D
"Three-centimeter area of serosanguineous drainage noted on the dressing to the left hip" is complete, accurate, and concise.
You might also like to view...
The nurse is preparing the care plan for a client who admitted to the unit after an abdominal hysterectomy to manage endometriosis. Which goal statements reflect the need for further development by the nurse?
Select all that apply. 1. The nurse will assess the vital signs every 2 hours. 2. The client will walk Q2h on the first postoperative day. 3. The client will report feeling better. 4. The client will begin a clear liquid diet on the first postoperative day. 5. The healthcare provider will prescribe oral analgesics on the first postoperative day.
You document your patient's vital signs into a bedside documentation device and are able to compare your patient's vital signs with patients who have similar diagnoses and similar medica-tions, and who are of a similar age. You are accessing:
a. E-mail. b. Telecommunications. c. A database. d. Technology.
When completing a community assessment, the nurse will
a. Identify community needs and clarify problems. b. Determine the weaknesses of a community. c. Perform the core functions of public health nursing. d. Assess individual needs within a community.
Which of the following statements is true about cephalosporins and penicillins?
A. The cephalosporins are used as substitutes for penicillins in the treatment of certain gram-positive infections. B. The mechanism of action of the cephalosporins is the same as that of the penicillins. C. The cephalosporins are usually less resistant than the penicillins to the bacterial beta-lactamase enzymes. D. The chemical structure of the cephalosporins is completely different from that of the penicillins.