Review the charting sample and determine which documentation error occ

QUESTION

Review the charting sample and determine which documentation error occurred.

1000: Hygienic care given
1100: Complaint of leg pain
1300: Appetite good, resting comfortably

a. Recording on the wrong chart
b. Failure to document an intervention
c. Failure to document a discontinued medication
d. Failure to record outcome of an intervention

ANSWER:

ANS: B
The nurse failed to document an intervention for the client’s complaint of leg pain. The interventions are actions that nurses perform in settings relevant to illness prevention, illness treatment, and health promotion. There is no evidence the nurse has recorded on the wrong chart. There is no evidence the nurse has failed to document a discontinued medication. The nurse has recorded the outcome of an intervention by stating the client has a good appetite and is resting comfortably.