Which chart entry represents appropriate documentation about the patient's pain assessment?

The patient is sleeping comfortably.

The patient rated the pain at 2 on a 0-to-10 scale.

The patient appears not to be in any pain.

The patient always complains about being in pain.

Answer and Explanation

The Correct Answer is B

Choice A rationale

"The patient is sleeping comfortably" is a subjective observation and does not provide a quantifiable measure of the patient's pain level. While comfort is important, this statement lacks specific information about the patient's pain experience and does not allow for consistent monitoring or evaluation of pain management interventions.

Choice B rationale

"The patient rated the pain at 2 on a 0-to-10 scale" is an example of appropriate pain assessment documentation. It uses a standardized pain scale, allowing the patient to quantify their pain intensity. This provides objective data that can be used to monitor changes in pain levels over time and evaluate the effectiveness of pain management strategies.

Choice C rationale

"The patient appears not to be in any pain" is a subjective interpretation by the nurse based on observation. It does not involve input from the patient about their pain experience. Pain is subjective, and a patient may be experiencing pain even if they do not outwardly appear to be in distress. Relying solely on observation can lead to underreporting and undertreatment of pain.

Choice D rationale

"The patient always complains about being in pain" is a generalization and does not provide specific information about the patient's current pain level. It can also introduce bias into future pain assessments. Each pain report should be documented objectively and based on the patient's current experience, not past complaints.

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Correct Answer is D

Explanation

Choice A rationale

Using correction tape is inappropriate as it obscures the original entry, violating the principle of maintaining a clear and accurate audit trail. This makes it impossible to determine what the original error was and who made it, which is crucial for accountability and legal purposes in healthcare documentation.

Choice B rationale

Shredding the original forms and rewriting them is unacceptable because it completely eliminates the original record. This action could be interpreted as an attempt to conceal errors or misrepresent information, which carries significant legal and ethical implications in patient care documentation.

Choice C rationale

Blacking out the error with a thick marker obscures the original information, making it impossible to review the mistake and understand the context. This method does not allow for verification of the initial entry or tracking of the correction process, which is essential for maintaining accurate medical records.

Choice D rationale

Drawing a single line through the incorrect information, making the correction clearly beside it, and then initialing and dating the change maintains the integrity of the original record while indicating who made the correction and when. This method ensures transparency and accountability in documentation, adhering to legal and professional standards for error correction in medical charts.

A. To prevent the patient from filing a malpractice lawsuit. B. To aid in the hospital's quality improvement program. C. To compare patient fall rates between nursing units in the hospital. D. To provide justification for the hospital to fire the nurse.

Correct Answer is B

Explanation

Choice A rationale

An incident report primarily focuses on documenting the facts of an event, not on preventing lawsuits. While a thorough report might indirectly help in legal defense by providing a clear record, its main purpose isn't legal protection. Legal strategies are separate from the incident reporting process.

Choice B rationale

Incident reports are crucial for a healthcare facility's quality improvement initiatives. By systematically documenting occurrences like patient falls, the hospital can analyze trends, identify potential risks and contributing factors, and implement strategies to prevent similar incidents in the future, thereby enhancing patient safety and care quality.

Choice C rationale

While incident reports from various units might be reviewed and compared as part of a broader quality improvement effort, the primary reason for completing an individual incident report is not solely for comparing fall rates between units. The immediate goal is to document the specific incident and identify local contributing factors.

Choice D rationale

Incident reports are designed to document events objectively. They are not primarily used as a basis for disciplinary action against a nurse. Disciplinary processes would involve a separate investigation to determine if negligence or policy violations occurred, based on various sources of information, not just the incident report.

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Which chart entry represents appropriate documentation about the patient's pain assessment?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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