A nurse is following appropriate documentation procedure when:
A. Quoting subjective information
B. Identifying in the client's record that an incident report was completed
C. Completing late entries with the time the procedure should have been done
D. Documenting immediately before administering client medications
A
A. For subjective data provide description of episode in quotation marks: onset, location, description of condition (severity; duration; frequency; precipitating, aggravating, and relieving factors).
B. A notation that an incident report was written is not included in the medical record.
C. When documenting a late entry, indicate the time of the late entry along with the action and an objective observation.
D. Immediately after (not before) administration document: time medication given, preliminary assessment (e.g., pain level, vital signs), client response or effect of medication
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