QLexNursing

📝 This entry reflects objective, measurable, and factual information, which is the gold standard for nursing documentation.

📝 It avoids judgmental language and instead clearly describes what was observed, including the type and size of drainage, allowing other healthcare providers to accurately interpret the client’s condition.

📝 Using precise measurements supports continuity of care and provides defensible documentation in the medical record.

📝 This statement demonstrates proper professional documentation that is clear, concise, and legally sound.

❌ Incorrect Options (Elaborated):

❌ “The client is uncooperative and refused to take their morning medication.”

❌ This statement contains subjective and judgmental language (“uncooperative”), which should be avoided.

❌ Proper documentation should instead describe the client’s behavior objectively, such as stating the client declined the medication without labeling their attitude.

❌ Judgmental wording can be misinterpreted and may create legal or professional issues.

❌ “A medication error was made on a previous shift. The client's vital signs are stable.”

❌ Medication errors should not be documented in the medical record.

❌ Such events are reported through an incident report, which is a confidential quality-improvement document.

❌ Including this information in the chart can have legal implications and does not follow documentation standards.

❌ “The client was administered 4 units of regular insulin.”

❌ While this statement is factual, it is incomplete and lacks critical details.

❌ Proper medication documentation should include the time, route, indication, and client response.

❌ Compared with the correct option, it does not best demonstrate comprehensive understanding of documentation principles.