Which is the most accurate example of documentation?
a. 7/27/14; 0945; pt. vomited; pt. looked better after episode—A. Nurse, LPN
b. 7/27/14; 0945; pt. vomited large amount; reduced nausea
c. 7/27/14; 0945; pt. reported less nausea after vomiting—A. Nurse, LPN
d. 7/27/14; 045; pt. vomited 200 ml of par-tially digested food; pt. states nausea has diminished—A. Nurse, LPN
D
Documentation should be completed immediately after care is given, never before care. It should be timed and dated, ending with the signature of the nurse performing the care or making the observation. Charting should be objective and describe only what is seen, heard, felt, or smelled.
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