A charge nurse is reviewing documentation in the medical record from a newly licensed nurse.

Exhibits

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The client has a history of major depressive disorder and alcohol use disorder. They have had previous hospitalization which has included detoxification. The client is inappropriate and is a huge fall risk. The provider has denied this RN's requests for physical or chemical restraints. Currently, the ICU and progressive care unit are full, and the client is being admitted to this medical unit. They appear 'medically stable. The client is alert, oriented to self and location. Denies pain. Sitting up in bed. The partner is at bedside and said that their spouse is always complaining or arguing

The nurse's documentation of the client being "inappropriate" is vague and unprofessional. Additionally, using the term "huge fall risk" without a specific assessment or plan to mitigate the risk (e.g., implementing fall precautions) is not adequate documentation. Further, the nurse’s reliance on physical or chemical restraints without exploring alternative interventions suggests a need for education on restraint use and patient safety practices.

The nurse's notes reflect a subjective description of the client's behavior as 'inappropriate' and 'complaining or arguing,' which is not objective or professional. It is important for nursing documentation to remain objective and to describe observed behaviors rather than labeling them. The statement that the client is "medically stable" should be supported by objective data rather than subjective observation, and it is important to note that mental health stability is also a crucial aspect of overall health.