Which of the following is the best example of accurate documentation?
A)"Abdominal wound is 5 cm in length without redness,edema,or drainage."
B)"OD to be irrigated qd with NS."
C)"No complaint of abdominal pain this shift."
D)"Patient watching TV entire shift."

Question

Quizplus · Accepted Answer

The use of exact measurements in documentation establishes accuracy.For example,charting that an abdominal wound is "5 cm in length without redness,edema,or drainage" is more descriptive than "large wound healing well." It is essential to know the institution's abbreviation list,and to use only accepted abbreviations,symbols,and measures (e.g. ,metric),so that all documentation is accurate and is in compliance with standards.For example,the abbreviation for every day (qd)is no longer used.If a treatment or medication is needed daily,the nurse should write out the word "daily" or "every day" on the written order or care plan.The abbreviation qd (every day)can be misinterpreted to mean O.D.(right eye).The term "no complaint" may indicate stoicism on the part of the patient.He may have been in excruciating pain but never complained of it.It also creates a question related to the assessment skills of the nurse.It is essential to avoid unnecessary words and irrelevant details.For example,the fact that the patient is watching TV is only necessary to report when this activity is significant to the patient's status and plan of care.

Which of the Following Is the Best Example of Accurate