Which of the following is evaluated as a legally appropriate notation?
a. "Dr. Green made an error in the amount of medication to administer."
b. "Client verbalized sharp, stabbing pain along the left side of chest."
c. "Nurse Williams spoke with the client about the surgery."
d. "Client upset about the physiotherapy."
B
Entries should be concise, factual, and accurate. The entry "Client verbalized sharp, stabbing pain along the left side of chest" is an example of an objective description of a client's behaviour.
The nurse should not document "physician made error." Instead, the nurse could chart, "Dr. Green was called to clarify order for medication administration."
The nurse should chart only for himself or herself. In this case, Nurse Williams should write the charting entry.
Only objective descriptions of the client's behaviour should be recorded. For example, "Client states, ‘I don't want physiotherapy! I want to go home!'"
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