The RN is documenting the patient's complaint of pain rated 6 on a scale of 0 to 10. Which chart entry would be the most appropriate, if made by the nurse?
A) Pt. complaining of pain. MD notified.
B) Pt complaining of pain rated at 6 on a scale of 0-10, states "My left leg is really hurting." Pt. grimacing, voice elevated. MD notified.
C) Pt. complaining of pain rated at 6 on a scale of 0-10. Appears to be in pain. MD notified.
D) Pt. complaining of pain rated 6. Wants more pain medication; appears to be drug-seeking. MD notified.

Question

Quizplus · Accepted Answer

With "Pt complaining of pain rated at 6 on a scale of 0-10, states 'My left leg is really hurting.' Pt. grimacing, voice elevated. MD notified," the entry contains the problem, the assessment, subjective comments, observations, and the plan. The entry "Pt. complaining of pain. MD notified," does not define the patient's pain. The entries "Pt. complaining of pain rated at 6 on a scale of 0-10. Appears to be in pain. MD notified" and "Pt. complaining of pain rated 6. Wants more pain medication; appears to be drug-seeking. MD notified" reflect opinions of the nurse.

The RN Is Documenting the Patient's Complaint of Pain Rated