Asked by Alina Avellaneda on Sep 27, 2024
A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?
A) Status unchanged, doing well
B) Patient seems to be in pain and states, "I feel uncomfortable."
C) Left knee incision 1 inch in length without redness, drainage, or edema
D) Patient is hard to care for and refuses all treatments and medications. Family is present.
Document
An official record that provides evidence or information.
Incision
A clean cut made through the skin and tissues during surgery, typically made using a sharp instrument.
Redness
An area of the skin that becomes red due to increased blood flow, often as a sign of irritation, injury, or inflammation.
- Comprehend the documentation process, including charting accurately and legal implications.
Learning Objectives
- Comprehend the documentation process, including charting accurately and legal implications.