Question

Evaluate the documentation entries below. Circle the

documentation errors. Rewrite the
documentation entry correctly.
Patient complaining of pain most of the shift. VS normal. .1
mg MSO4 given.
Pat

Answer 1

The provided documentation entry contains errors and can be corrected by adding missing information and expanding abbreviations.

Step-by-step explanation:

The documentation entry provided contains several errors. First, it lacks important information such as the patient's name and demographics.

Second, it does not specify the type of pain the patient was experiencing. Third, the abbreviation 'VS' should be expanded to 'vital signs' to provide clarity.

Fourth, the dosage should be written as '0.1 mg' instead of '.1mg'. Lastly, the medication abbreviation 'MSO4' should be expanded to 'morphine sulfate' for better understanding.

A correct documentation entry could be: 'Patient John Doe complained of abdominal pain throughout the shift.

Vital signs remained within normal limits. A dose of 0.1 mg of morphine sulfate (MSO4) was administered for pain management.'