Guidelines should be followed when documenting patient care.Which one of the following does the nurse recognize as the most appropriate notation?
A) "1230 hours: Patient's vital signs taken"
B) "0700 hours: Patient drank adequate amount of fluids"
C) "0900 hours: Morphine given for lower abdominal pain"
D) "0830 hours: Increased IV fluid rate to 100 mL per hour"

Question

Quizplus · Accepted Answer

The most appropriate notation is one that is concise, accurate, and contains relevant information. Option D provides specific details about the patient's care, including the time, the intervention, and the rationale for it. This allows for easy tracking of the patient's progress and is helpful when coordinating care with other members of the healthcare team. Option A is too vague and fails to provide any context for the vital signs, while option B is subjective and does not offer any concrete information about the patient's condition. Option C is also specific but lacks the explanation for the intervention.

Guidelines Should Be Followed When Documenting Patient Care