The nurse makes a late entry in a client's record. Which of the following is the best example of how to document this type of situation?
a. "2030 hrs: Client received aspirin and oxycodone (Percodan; 1 tablet) PO an hour before going to radiology."
b. "1215 hrs: I gave the client morphine 10 mg IM at 1110 hours, but did not docu-ment it then."
c. "1445 hrs: Acetaminophen 500 mg given for temperature of 38.1°C."
d. "2030 hrs: Abdominal dressing change at 1930 hrs. No s/s of infection, and wound edges approximating well."
C
"1445 hrs: Acetaminophen 500 mg given for temperature of 38.1°C" is the best example of a late entry. The time is indicated along with the action and an objective observation.
The notation "2030 hrs: Client received aspirin and oxycodone (Percodan; 1 tablet) PO an hour before going to radiology" is not complete. It does not indicate why the aspirin and oxycodone (Percodan) were given (i.e., What was the client's level of pain? Where was the pain located?).
The nurse does not need to document about himself or herself, only about the client. In the entry "1215 hrs: I gave the client morphine 10 mg IM at 1110 hours, but did not document it then," the nurse does not indicate why the morphine was given (i.e., What was the client's level of pain? Where was the pain located?).
The entry "2030 hrs: Abdominal dressing change at 1930 hrs. No s/s of infection, and wound edges approximating well" is not complete. It does not state the size of the wound, type of dress-ing used, or the client's tolerance of the procedure.
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