Guidelines should be followed when documenting patient care. Which one of the following does the nurse recognize as the most appropriate notation?
a. "1230 hours: Patient's vital signs taken"
b. "0700 hours: Patient drank adequate amount of fluids"
c. "0900 hours: Morphine given for lower abdominal pain"
d. "0830 hours: Increased IV fluid rate to 100 mL per hour"
D
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A The entry "1230 hours: Patient's vital signs taken" does not indicate what the patient's vital signs were.
B The entry "0700 hours: Patient drank adequate amount of fluids" does not provide the specific amount that the patient drank. Stating "adequate" is subjective, not objective.
C The notation "0900 hours: Morphine given for lower abdominal pain" does not have the patient describe his or her pain, or rate it according to a pain scale for comparison later. It also does not indicate whether the patient's pain was in the lower left or lower right quadrant, or both.
D Information within a recorded entry must be complete, containing appropriate and essential information. The notation "0830 hours: Increased IV fluid rate to 100 mL per hour" provides the time and action taken by the nurse, including the reason for doing so.
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