Question

The nurse documents in the patient record, '0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated, physician notified, and analgesic administered as ordered with adequate relief. J. Doe RN.' Which statement about the documentation is most accurate?

a. The documentation is inadequate because the pain is not described on a scale of 1 to 10.
b. The documentation is good because it shows immediate responsiveness to the problem.
c. The documentation is acceptable because it includes assessment, intervention, and evaluation.
d. The documentation is unacceptable because it is vague, nondescriptive data without supportive data.

Answer 1

The nurse's documentation is acceptable as it includes the necessary components of assessment, intervention, and evaluation regarding the patient's severe pain and subsequent relief.

Step-by-step explanation:

The nurse's documentation is most accurately described by option c. The documentation is acceptable because it includes assessment, intervention, and evaluation. The nurse assessed the patient's presentation of severe pain and reluctance to ambulate; appropriate interventions were made by notifying the physician and administering an analgesic; and an evaluation followed, noting the relief obtained from the analgesic. While the pain scale rating can enhance documentation, its absence does not necessarily make the record inadequate, as the nurse has clearly described the observed symptoms, conducted interventions, and evaluated the outcome.