Documentation and the Nurse Care Planning Process Assignment

Assignment Task

Part A - Evaluation

Review the case of Mr. John Smith and the progress note entry provided. Evaluate the nurse’s documentation and discuss what information was-written well and the areas that could be improved.

Part A - Case study 

Mr. John Smith, who is 80 years old, was admitted in medical ward this morning for consistent back and shoulder pain. He has a past medical history of hypertension and type 2 diabetes mellitus. He told the admitting nurse that he has lost interest in many of his normal activities because of the constant pain. He is scheduled for an MRI tomorrow. You read the following entry by a previous nurse:

10 - Patient is a complainer. I listened to him for 15 minutes with no success. BP 210/90, and 180/70. P 72, R 18.

12 - Refused lunch.

2 - Patient fell out of bed. Looks fine.

Evaluation of the above documentation

Rex notes followed some of the general guidelines in recording as his writing was legible, he used the 24-hour clock or military clock, he also signed each entry correctly and it was documented in a timely and chronological manner. According to Courtney-Pratt (20XX, p.) these are essential elements in recording patient data to safeguard the patient’s safety and for legal reasons.

However, Rex did not include the patient’s statement or any objective data about the client’s pain. In pain assessment, it is important to use a pain scale to help evaluate the effectiveness of the treatment (Reference).  Furthermore, Rex did not identify the dose of paracetamol he gave to the patient. It is important for patient record to be complete to be helpful to the health professional (Courtney-Pratt 20XX, p.X).

So this is how it should be done please read through the example and instruction

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