While giving an end-of-shift report at 1915, a nurse realizes that a client's physical therapy session that occurred at 1030 was not documented. Which of the following is the correct method for adding this information to the client record?
a. Ask the oncoming nurse to make the notation for you.
b. Date and time the entry for 1915; then write "Late Entry (date-1030)" before making the addition.
c. Do not add the information to the chart, but complete an incident report.
d. Do nothing, since the physical therapist documented the session in the multidisciplinary progress notes.
B
Entries should be made chronologically, starting with date and time, observation, intervention, and evaluation; it is essential to chart periodically throughout the period in which care is being provided so that significant changes in client condition are recorded as they occur. If pertinent data are not documented in a timely manner, late entries to a client's record may be permitted, according to facility policy.
You might also like to view...
Every day a child came into the school nurse's office with vague complaints, but sometimes it seemed to the nurse that the child just wanted to talk and be listened to for a while. Unfortunately, the child took up almost 15 minutes of the nurse's very busy day. Which of the following actions should be taken by the nurse?
a. Ask a staff person to talk with the child so the nurse could complete required tasks b. Continue to listen while assessing for possible underlying problems c. Refer the child to a private physician for follow-up on the constant physical symptoms the child presented d. Talk to the teacher about not letting the child leave the classroom unless obvious symptoms (fever, vomiting) of illness were present
An adult female client is diagnosed with chronic fatigue syndrome. Which symptom would not be associated with this condition?
A) Feeling unrefreshed after adequate sleep B) Joint pain with swelling C) Mild fever D) Confusion
Nausea/vomiting from which cause is helped best by antihistamines?
a. Allergies b. Opiate drugs c. Cancer chemotherapy d. Exposure to bad odors
The nurse would question a prescription for metoclopramide for which of the following clients?
a. client with GERD c. a child under six years of age b. client with a seizure disorder d. a client with a gastric tube