Find the missing piece
Patient reports pain. PRN medication administered.
what important assessment information is missing?
The patients pain rating/location.
Which statement is most problematic>
A. Patient ambulated 50 feet with standby assistance.
B. Patient appears to be doing fine.
C. Patient reports pain 4/10.
D. Lung sounds clear bilaterally.
B. Patient appears to be doing fine.
"Patient reports headache 5/10. PRN medication given."
What is missing?
- Pain rating
- Symptoms
-Medication given
-Time
-Route/dose
Opionin
You give a PRN pain medication. Is documenting only "PRN medication given" enough?
No. Documentation should reflect the indication, medication/interventions, and appropriate reassessment/response.
Patient ambulated in hallway.
What could make this documentation more complete?
Distance, level of assistance, tolerance/response, and any other relevant observations.
A nurse documents:
"Patient was rude and difficult."
Why is this documentation a red flag?
It is subjective and judgmental. Documentation should describe specific observable behaviors and patient statements.
"Patient ambulated from bed to bathroom."
What is missing?
- How did the resident ambulate 1 or 2 persons assist?
- How did they tolerate it?
- Did they experience any difficulty? Pain?
"Patient refused blood glucose check."
Fact
A patient receives PRN medication for pain rated 8/10. What should you document during follow-up?
The patient's response, including reassessed pain level and relevant clinical findings.
Patients' blood pressure is elevated.
what's missing?
The actual blood pressure reading, along with relevant context such as time and assessment findings.
Which is better documentation?
A. Patient is confused.
B. Patient repeatedly asks where they are and is unable to state the current location.
B
"Patient reports nausea 6/10. Thirty minutes later, nausea is 2/10 and patient is tolerating oral fluids."
What is missing?
- Did resident receive an antiemetic? If so, what kind? Dose? Time?
"Patient seems confused."
Opinion / Vague
How can you make this more objective?
- "Patient unable to correctly state location and repeatedly asks the same question."
Why is reassessment after a PRN medication important?
It demonstrates the patient's response to the intervention and helps communicate whether the intervention was effective or whether additional action is needed.
Patient received PRN medication and feels better.
Name at least 3 pieces of information that could make this documentation stronger.
- Medication/dose/route
-Indication or symptoms
- Time administered
-Reassessment findings
- Patients response
“Patient had a bad night. Was very anxious and acting weird. Gave medication and patient is fine now.”
What are the red flags in this sentence?
- "bad night"
- "very anxious"
-"Acting weird"
-"Gave medication" = doesn't identify medication/intervention
-No indication/reason for medication
- No time/dose/route
- "fine now" = vague
-No reassessment findings
-No objective assessment information
"Patient found sitting on the floor beside the bed. Patient denies hitting head and reports no pain. Nurse assesses patient and obtains vital signs. MD/ DON/ Administrator and family notified."
What kind of information should be included in the documentation?
- Objective findings, patient's statements, assessment, vital signs, interventions, notifications, response.
"Patient is uncomfortable."
Potentially vague. How can you make this more objective?
- what is making them uncomfortable? Are they verbally telling you? non-verbally?
Patient receives a PRN medication but develops a possible adverse reaction. What should the nurse document?
Objective assessment findings, medication/intervention, patient's symptoms/response, interventions taken, notifications/escalation as appropriate, and subsequent reassessment—following facility policy.