Practice Question
Which of the following entries best demonstrates appropriate documentation?
Answer Choices:
Correct Answer:
"Patient reports pain 6/10 in left hip; acetaminophen 650 mg given per order
Rationale:
💠 This entry demonstrates objective, factual, and complete documentation, including the patient’s subjective report, the location and intensity of pain, and the nursing action taken.
💠 It uses clear and measurable data (6/10) rather than vague terms like “okay” or “better,” ensuring accuracy and accountability in the patient’s medical record.
💠 Effective documentation supports continuity of care, legal protection, and communication among the healthcare team.
💠 Nurses should always chart what they observe, what the patient reports, and what actions were taken in response to findings.
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This question is from NR449_Quiz1_Mod1_BSNOL which contains 9 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Fundamentals
- Answer Choices: 4