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Question
a resident in a skilled nursing facility for short - term rehabilitation after a hip replacement tells the nurse, \i dont want any more blood taken for those useless tests.\ which narrative documentation should the nurse enter in the clients medical record?
a client irritable, uncooperative, and refuses to have blood collected. healthcare provider notified.
b healthcare provider notified of failure to collect specimens for prescribed blood studies.
c blood specimens not collected because client no longer wants blood tests performed.
d healthcare provider notified of clients refusal to have blood specimens collected for testing.
Medical documentation must be objective, factual, and include key actions taken. Option A includes subjective terms ("irritable, uncooperative"). Option B is vague about the reason for failed collection. Option C omits that the healthcare provider was notified, which is a critical action. Option D clearly states the client's refusal and that the provider was notified, meeting objective documentation standards.
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D Healthcare provider notified of client's refusal to have blood specimens collected for testing