A nurse is assessing his patients in the morning and finds that a frail 85-year-old female patient is soiled in bed. The patient reports that she has asked to be cleaned numerous times and has been ignored. Of the following, which demonstrates appropriate documentation in the patient's chart?
•This is the correct example: "The patient was found soiled; incontinent of urine and feces. She was given a bed bath and provided skin care. Her skin was reddened on the buttocks; emollient applied."
•Documentation must stick to objective descriptions of what happened and any assessments and interventions performed. Personal biases or information that implies misconduct should never be documented in the patient's chart.
•If a nurse suspects that a patient is being neglected or mistreated, an incident report should be made and the physician informed, but this should never be mentioned in the patient's medical record.
•Nurses are mandated reporters. If abuse or medical neglect are suspected, the authorities should be informed.
•The examples that includes that the patient she says she was "ignored for hours" by the night shift RN and being left alone all night by the night shift RN are inappropriate to document in the medical record but could be included in an incident report.
•Her skin was reddened on the buttocks; emollient applied. Incident report made. - An incident report should never be mentioned in the medical record.