A nurse is documenting a patient's condition in a narrative chart. The patient reports sudden onset chest pain while gardening Which of the following chart entries best exemplifies accurate and complete narrative charting?
Patient has chest pain. Needs to see a doctor.
Patient states, I suddenly felt a sharp pain in my chest while gardening Rates pain as 6/10. No radiating pain reported. Blood pressure: 145/95 mm Hg Heart rate: 100 beats/min, regular.
The patient was gardening when they got chest pain. Blood pressure high
The patient felt pain in the chest while in the garden. No further information provided
The Correct Answer is B
A. Patient has chest pain. Needs to see a doctor.: This entry is vague and lacks essential subjective and objective data. It does not include the client’s own words, pain characteristics, or vital signs. Narrative charting requires detailed, specific, and measurable information.
B. Patient states, “I suddenly felt a sharp pain in my chest while gardening.” Rates pain as 6/10. No radiating pain reported. Blood pressure: 145/95 mm Hg. Heart rate: 100 beats/min, regular.: This entry includes subjective data in the client’s own words, objective assessment findings, and relevant vital signs. It clearly documents onset, quality, severity, and associated findings. This reflects accurate, complete, and legally sound narrative charting.
C. The patient was gardening when they got chest pain. Blood pressure high: This statement lacks specific pain description, numeric values, and patient-reported details. Terms such as “high” are non-measurable and imprecise. Incomplete data limits clinical usefulness.
D. The patient felt pain in the chest while in the garden. No further information provided.: This entry is incomplete and omits critical assessment details such as pain severity, vital signs, and associated symptoms. Narrative charting must provide sufficient information to guide clinical decision-making.
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Related Questions
Correct Answer is D
Explanation
A. Ignore as it is not the nurse's responsibility: Maintaining patient confidentiality is a shared professional and legal responsibility. Ignoring a breach could violate HIPAA regulations and ethical standards, placing patients and staff at risk.
B. Wait for the colleague to return and discuss the issue with them: Waiting delays immediate protection of sensitive information and could result in unauthorized access. Patient privacy must be addressed without delay.
C. Inform the hospital administration immediately: While reporting repeated breaches may be appropriate, the immediate concern is to secure the information to prevent exposure. Administrative reporting alone does not address the urgent risk.
D. Close the computer screen and remind the colleague to log out: Securing the unattended computer prevents unauthorized access to patient records and maintains confidentiality. Promptly reminding the colleague reinforces professional accountability and compliance with privacy regulations.
Correct Answer is A
Explanation
A. The preferences and values of the client: Evidence-based practice integrates clinical expertise with the best available research and, importantly, the client’s preferences, values, and needs. Considering the client ensures care is individualized, ethical, and more likely to be accepted.
B. The ease of implementation: While practical feasibility is a consideration, it is secondary to ensuring that interventions align with client values and evidence-based recommendations. Ease alone does not justify care decisions.
C. The cost-effectiveness of the intervention: Cost is relevant for resource management, but prioritizing it over client-centered considerations may compromise individualized care and ethical practice.
D. The latest medical trends: New treatments or trends are not inherently evidence-based. Nurses must critically evaluate research quality and applicability rather than following trends without considering effectiveness and client relevance.
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