RN Nursing · Documentation · Practice question
Which data entry follows the recommended guidelines for documenting data?
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"Patient's kidneys are producing sufficient amount of measured urine."
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"Patient is overwhelmed by the diagnosis of breast cancer."
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✓
"Following administration of 2L of oxygen the client's saturation increased to 98%."
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"S. Johnson RN was unable to change the dressing due to the number of patients admitted last night.
Answer & explanation
Correct: "Following administration of 2L of oxygen the client's saturation increased to 98%."
Recommended documentation guidelines require entries to be objective, specific, accurate, and measurable. The entry describing oxygen administration states a precise intervention — 2 liters of oxygen — and a measurable outcome — saturation increased to 98% — making it fully objective and verifiable by any reader. This reflects best practice for clinical documentation. The entry stating the patient's kidneys are producing a 'sufficient amount' of urine uses subjective, vague language without citing an actual measurement; a proper note would record the specific output in milliliters. The entry claiming the patient 'is overwhelmed by the diagnosis' is an interpretive, subjective conclusion rather than an observation of observable behavior; proper documentation would describe what the patient said or did, such as 'patient began crying and stated she could not cope.' The entry about S. Johnson RN being unable to change the dressing due to patient census attributes a task omission to a systemic staffing problem, which is inappropriate in the legal medical record and shifts blame rather than documenting clinical care. Good documentation is factual, precise, and free from inference or blame-shifting, which is why only the oxygen-saturation entry meets the standard.
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