A registered nurse in the United States is documenting care after a patient falls while walking to the bathroom. Which entry is appropriate for the health record?

Correct answer: C. The patient was found seated on the floor beside the bathroom

  • A. The patient was careless and ignored instructions
  • B. An incident report was completed after the fall
  • C. The patient was found seated on the floor beside the bathroom
  • D. The nurse believes the patient fell because of poor judgment

Explanation

The health record should contain objective observations, assessment findings, interventions, notifications, and the patient's response. The nurse should not mention completion of an incident report in the patient's record. Blame and unsupported opinions are not appropriate clinical documentation.

Submitted by a TestUstad contributor and published by the TestUstad editorial teamLast updated
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US nursing law and ethics include state nurse practice acts, scope of practice, standards of care, negligence, malpractice, documentation, confidentiality under HIPAA and informed consent. Ethical reasoning applies autonomy, beneficence, nonmaleficence, justice and fidelity to conflicts such as refusal of treatment, advance directives, privacy breaches and mandatory reporting, which are not the same as legal liability.

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