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Mr. Larsen, a patient in a LTC facility, was involved in an altercation with another patient. Which of the following demonstrates appropriate documentation of the incident in Mr. Larsen's chart?

Explanation

•Mr. Larsen was pushed to the floor by another patient, witnessed by this RN. The patients were separated without further incident. Mr. Larsen has no bruises or deformities and the patient reported no pain. HR 105, BP 140/90, RR 20, 98.5 F, 99% O2 sat on RA. The patient was not on fall precautions; reports no dizziness. A&O x3. MD and DPOA notified. No further orders.

•Documentation of an incident involving two patients in a patient chart should never name the other patient involved, only objective information about the incident.

•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 fall precautions- also document any patient education.

Incorrect options:

•Incorrect documentation named the other patient involved, violating patient confidentiality, or gave unnecessary details about the patient interactions.

•Other incorrect options left out information about the assessment or the actions taken afterward. Were the patients separated? Who was informed after this incident? Were there orders to put anyone on precautions?

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