Which information should be included when documenting a patient’s telephone conversation with a family member?
Correct answer: B. The exact time, caller identity, message, and action taken
- A. The nurse’s personal opinion about the family
- B. The exact time, caller identity, message, and action taken
- C. A general statement that the family was difficult
- D. Only the fact that a telephone call occurred
Explanation
A complete telephone note identifies when the call occurred, who called, what was communicated, and what follow-up occurred. Opinions and vague descriptions do not provide a reliable clinical record.
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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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