A nurse is documenting after a 76-year-old female with dementia was found on the floor after using the bathroom by herself. The nurse documents the following in the chart: Patient fell on the bathroom floor at 1715.
Of the following, which is an example of inappropriate documentation of this incident?
•The following is an example of inappropriate documentation of an unwitnessed fall: "Patient fell on the bathroom floor at 1715 hrs."
•Documentation should include where the patient was found and who found them and any objective observations only. It should be noted if they were on precautions of any kind. Never document that the patient fell unless someone actually witnessed the fall.
•Assess the patient and record bruises, lacerations, pain, or deformity. Record vital signs and mental status. Document who was notified and any orders given like being put on fall or seizure precautions. Also, document any patient education given.
•POA and MD informed; Pt put on fall precautions. This is appropriate to
•Patient has a bruise on her right thigh and reports 4/10 pain at the thigh. Tylenol 650 mg PO given at 1740 hrs. Pain 1/10 at 1830 hrs. This is appropriate documentation of assessment and intervention of pain.
•Patient reported that she "lost her balance" while toileting. It is acceptable to include a patient report of what happened.