The following documentation was entered in the client's medical record: "The client was found lying on the floor. Dr. X was notified. Apparently, the restraints were improperly applied." Which statement best describes this documentation?
A) Appropriately written
B) Inappropriate because it places blame on an individual
C) Inappropriate because it does not include that the client's family was notified
D) Appropriately written because it only documents the facts

Question

Quizplus · Accepted Answer

1. Documentation in the chart following an incident should be a statement of the facts; no blame should be placed.
2. The documentation is not appropriately written because it implies that someone was to blame for the incident.
3. The documentation must indicate that the physician was notified, not that the client's family was notified.
4. The documentation is not appropriately written; no blame should be placed.

The Following Documentation Was Entered in the Client's Medical Record