Question

Evaluate the documentation entries below. Circle the documentation errors. Rewrite the documentation entry correctly. 1. Patient complaining of pain most of the shift. VS normal. \( 1 \mathrm{mg} \mat

Answer 1

The original documentation entry was incomplete and had errors including lack of specifics about the patient's pain, vital signs, and medication details. A correct documentation includes detailed complaints, exact vital signs, full medication details, and nursing actions taken.

Step-by-step explanation:

The original documentation states “Patient complaining of pain most of the shift. VS normal. 1 mg”. This entry is incomplete and has several documentation errors, which could impact patient care and medical record keeping. A correct documentation entry should include the patient's specific complaints, the exact vital signs (VS), the complete medication details, and the nursing actions taken in response to the patient's complaints.

An improved version of the documentation might look like this:

“Patient reported moderate to severe abdominal pain throughout the shift, rating it 6/10 on the pain scale. Vital signs stable with blood pressure 120/80 mmHg, heart rate 78 bpm, temperature 98.6°F, and respiratory rate of 16 breaths per minute. Administered 1 mg of morphine intravenously for pain relief at 1400 hours with the patient reporting a decrease to 3/10 on the pain scale after 30 minutes. Will continue to monitor for further pain and response to medication.”