Let’s Practice

Review the following notes using the principles and guidelines on nursing
documentation.

Documentation #1

10/24/2021 Received via stretcher at 1400 from ER with daughter Jaja

1430 present. Report received from A. Galla, RN. BP 140/90, PR
84, RR 24, Tem 38.5 C, O2 Stats 94% on room air. See
admission for partial completion

The severity of the client’s pain and the emotional

status was forgotten on this nursing documentation, but it
says there to see the admission for partial completion, I think
it should be on the assessment admission form so there is
no need to repeat the information in the progress notes as it
may increase the odds for mistakes or errors.

Documentation #2

10/21/2021 Physician aware of client’s deteriorating condition. C.

2215 Williams, RN.

For me, it lacks the basic parts of accurate

documentation and does not adhere to nursing
documentation principles and guidelines. In writing a
documentation, the physician should be identified, as well as
the date and time, and method of notification. The nurse
must also offer a detailed description of what he or she
reported. When consulting with a physician, he or she must
write down exactly what the physician said. If there are any
additional orders, nurses should write a note in the progress
notes to inform the staff. A nurse should also note whether
there were no new instructions.