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kkeehner kkeehner
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6 years ago
You chart the following: 7/16/00 0900 C/o sharp, constant pain in L hip, requesting pain medication. BP 98/50, P 62, R 10. Oriented 3. Responds to verbal stimuli but easily returns to sleep.
 
  Need to wait for pain medicine explained due to low BP & resp. and length of time since last injection 3 hours (order is for q4 hours). Will reassess in 15 minutes. What type of documentation is this?
  1. an explanation of why medication is withheld
  2. admit note
  3. observation of psychosocial status
  4. client teaching note
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LyraBurroughsLyraBurroughs
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6 years ago
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kkeehner Author
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6 years ago
This site is awesome
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Correct Slight Smile TY
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this is exactly what I needed
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