Editing Management of Care – RN Practice Questions (section)

==Question 12==
A client is found on the floor beside the bed. Which entry in the medical record is '''most appropriate'''?
# "Client fell out of bed because the assistive personnel left the side rail down."
# "Found client on floor at 0410. Vital signs stable. Provider notified. Incident report completed."
# "Found client on floor beside bed at 0410. Assessed for injury; no deformity or bleeding noted; vital signs obtained and recorded; provider notified; neurologic checks initiated per protocol."
# "Client had an unwitnessed fall during the night. Appears no harm was done."

'''Answer:''' 3.

''Rationale:'' Documentation must be factual, objective, complete, and timely, and should record what was observed, what was done, and how the client responded. Option 1 records blame and an unwitnessed assumption about cause. Option 2 documents that an incident report was completed; the incident report is an internal risk-management tool and its existence should not be recorded in the medical record. Option 4 is vague and states a conclusion ("appears no harm") rather than assessment findings.