The following documentation was written on a chart: ?The client was found lying on the floor. Dr. X was notified. Apparently the restraints were improperly applied.? Which statement best describes this documentation? The documentation is:
1. Appropriately written.
2. Inappropriate because it places blame on an individual.
3. Inappropriate because it does not include that the client was notified.
4. Appropriately written because it only documents the facts.
2
Explanation: 1. Documentation in the chart following an incident should be a statement of the facts and no
blame should be placed. The documentation is not appropriately written because it infers that
someone was to blame for the incident. The documentation must indicate that the physician
was notified, not that the client was notified. The documentation is not appropriately written if
it documents only the facts because more than just facts are documented.
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