Evaluate the following documentation found in the medical record of a resident. It was provided by an LPN/LVN charge nurse relative to an incident that occurred while resident care was being provided by a nursing assistant.
July 1, 2009, 8:10 AM
While administering meds on Wing 1, I heard someone sobbing in the shower room on that wing. On entering the shower stall, I found Mrs. Garrity crying and shivering. She was sitting naked on the shower chair and was alone in the room. She stated that Becky, her nursing assistant, told her she had to leave for a phone call. I covered Mrs. Garrity with a bath blanket that was on the shelf in the bathroom. At that point Becky returned and confirmed that she had received a phone call. I think the in-service director needs to review the procedure for showering a resident with Becky and the policy about personal phone calls. Becky and I discussed the discomfort caused to Mrs. Garrity by her actions. She listened to my comments without defensiveness.
The documentation should be evaluated as
a. complete and appropriate.
b. appropriate but incomplete.
c. meeting agency and regulatory standards.
d. not meeting criteria for good documentation.
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