Review the following chart entry. Then rewrite the entry using the guidelines for documentation explained on page 81 in your textbook.
Nurse's Progress Notes
| Date |
Time |
Nursing Care Notes |
| 12/16/15 |
12:30 p.m. |
This crabby patient didn't eat any of her breakfast lunch. |
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| 12/16/15 |
3:00 p.m. |
She is such a complainer—like her ankle is always hurting! |
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Her vital signs are OK |
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|
Susie Smith |
Nurse's Progress Notes