Coordinated CarePregunta 9 de 120

The LPN/LVN is documenting in the electronic health record. Which entry is written correctly?

a."Client reports pain rated 7 of 10 in right lower abdomen at 0900."
b."Client seems to be doing fine today."
c."Client is being difficult and uncooperative."
d."Client probably has appendicitis."

Explicación

Documentation should be objective, specific, and factual, including measurable data and time. Subjective judgments and unauthorized diagnoses are inappropriate. Clear entries support continuity and legal accuracy.

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