Question

A nurse is caring for a client who received a sedative medication at bedtime and becomes confused during the night. The client falls while getting out of bed, sustaining a laceration to the head that requires suturing. Which of the following notations should the nurse make when documenting in the client's medical record?

a. 'Client found lying on the floor with a 3-cm laceration 1 cm above the left eyebrow. Client oriented to name only.'
b. 'Client found lying on the floor with blood on his face. Assistive personnel forgot to put side rails up at bedtime.'
c. 'Client fell out of bed and cut his forehead due to sedative-induced confusion.'
d. 'Client fell out of bed and received a facial laceration when his head hit the bedside table. See incident report in the medical record for further details.

Answer 1

When documenting in a client's medical record after an incident, the nurse should provide specific, objective details without placing blame. The correct notation is the one that states the facts observed about the client's condition and mental orientation.

Step-by-step explanation:

The nurse should document the incident objectively and factually. The appropriate notation to make when documenting in the client's medical record is: 'Client found lying on the floor with a 3-cm laceration 1 cm above the left eyebrow. Client oriented to name only.'

This notation is specific, objective, and does not place blame or include unnecessary details. It details the client's condition and mental status without speculation on the cause or assigning responsibility. This type of documentation helps ensure legal protection and supports quality patient care. Notations should be followed by an incident report which provides a full detailed account, including an analysis of why the incident occurred and measures taken to prevent future occurrences.