Which entry will require follow-up by the nurse manager? Show 0800 Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. Call bell within reach. Bed monitor on. ——————-Jane More, RN 0810 Notified primary care provider of patient's status. New orders received. ——————-Jane More, RN 0815 Portable x-ray of L hip taken in room. States, "I feel fine." ——————-Jane More, RN 0830 Incident report completed and placed on chart. ——————-Jane More, RN Sets with similar termsWhich chart entry would the nurse document in a patient's chart?Which chart entry would the nurse document in a patient's chart? Right abdominal dressing dry and intact. When answering questions about charting, remember the more descriptive and objective the charting entry is, the better.
What is included when documenting the patient chart?As such, the chart should include all pertinent details from a nurse's contact with the patient. This includes all care provided, including patient education and relevant family interactions. Everything should be documented to medical necessity in order to provide a thorough record of care.
What should you not document in a patient's chart?7 Common Pitfalls to Avoid in Charting Patient Information. Failing to record pertinent health or drug information. ... . Failing to document prior treatment events. ... . Failing to record that medications have been administered. ... . Recording on the wrong patient's chart. ... . Failing to document discontinuation of a medication.. What are the guidelines to use when charting?General Charting Guidelines. Double-check you are charting in the right chart.. Know your facility's policies.. Chart facts and be as descriptive as possible.. Be precise in your charting and measurements.. Write so other people can read it.. Chart as soon as you finish care.. Record the proper date and time.. |
After providing care, a nurse charts in the patient’s record. which entry should the nurse document?
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