A nurse is documenting a patient’s pain assessment. Which entry is most useful for continuity of care?
Correct answer: C. Patient reports pain of 7 out of 10 in the lower abdomen
- A. Patient is uncomfortable
- B. Patient has severe pain
- C. Patient reports pain of 7 out of 10 in the lower abdomen
- D. Patient appears to have a pain problem
Explanation
The numerical rating and specific location communicate measurable information that another nurse can reassess. The other entries are vague and do not provide a consistent basis for evaluating treatment.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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