QuestionAugust 16, 2025

A nurse is preparing to document client care in the electronic health record for a client who is postoperative. Which of the following should the nurse include in the documentation? A verbal prescription from the provider taken by the charge nurse Entry of the completion of a procedure in advance A treatment that was refused by the client Subjective findings regarding the client's pain tolerance

A nurse is preparing to document client care in the electronic health record for a client who is postoperative. Which of the following should the nurse include in the documentation? A verbal prescription from the provider taken by the charge nurse Entry of the completion of a procedure in advance A treatment that was refused by the client Subjective findings regarding the client's pain tolerance
A nurse is preparing to document client care in the electronic health record for a client who is postoperative. Which of the following should the nurse include in the documentation? A verbal prescription from the provider taken by the charge nurse Entry of the completion of a procedure in advance A treatment that was refused by the client Subjective findings regarding the client's pain tolerance

Solution
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Answer

A treatment that was refused by the client Explanation 1. Identify Relevant Documentation Include only factual, objective, and relevant information in the documentation. 2. Evaluate Each Option - **Verbal prescription**: Should be documented if it was taken by the nurse involved. - **Entry of completion in advance**: Not appropriate; document only after completion. - **Treatment refused**: Must be documented as it affects care. - **Subjective findings**: Document only if they are directly reported by the client. 3. Determine Correct Inclusion The treatment refused by the client should be documented as it is a critical part of the client's care and decision-making process.

Explanation

1. Identify Relevant Documentation<br /> Include only factual, objective, and relevant information in the documentation. <br /><br />2. Evaluate Each Option<br /> - **Verbal prescription**: Should be documented if it was taken by the nurse involved.<br /> - **Entry of completion in advance**: Not appropriate; document only after completion.<br /> - **Treatment refused**: Must be documented as it affects care.<br /> - **Subjective findings**: Document only if they are directly reported by the client.<br /><br />3. Determine Correct Inclusion<br /> The treatment refused by the client should be documented as it is a critical part of the client's care and decision-making process.
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