After providing care,a nurse charts in the patient's record.Which entry should the nurse document?
A) Appears restless when sitting in the chair
B) Drank adequate amounts of water
C) Apparently is asleep with eyes closed
D) Skin pale and cool

Question

Quizplus · Accepted Answer

A factual record contains descriptive,objective information about what a nurse sees,hears,feels,and smells.An objective description is the result of direct observation and measurement.For example,"B/P 80/50,patient diaphoretic,heart rate 102 and regular." Avoid vague terms such as appears,seems,or apparently because these words suggest that you are stating an opinion,do not accurately communicate facts,and do not inform another caregiver of details regarding behaviors exhibited by the patient.Use of exact measurements establishes accuracy.For example,a description such as "Intake,360 mL of water" is more accurate than "Patient drank an adequate amount of fluid."

After Providing Care,a Nurse Charts in the Patient's Record