A nurse is reviewing the medical record of a child who is scheduled to receive a varicella immunization. Which of the following findings in the client's record should the nurse recognize as a contraindication?

Incident report

When a nurse makes a medication error, such as administering an incorrect dose or an extra dose, it is important to document the incident in an incident report. Incident reports are confidential documents that provide a record of the event, facilitate communication among healthcare providers, and allow for further investigation and analysis to prevent future errors.

Provider's progress notes in (option A) is incorrect. The provider's progress notes are typically used to document the provider's assessment, diagnosis, treatment plan, and progress of the client. Medication errors made by nursing staff are not typically documented in the provider's progress notes.

Controlled substance inventory record in (option C) is incorrect. The controlled substance inventory record is used to track the administration and use of controlled substances. It may not be the appropriate location to document a medication error. However, it is important to follow institutional policies regarding the documentation of medication errors involving controlled substances.

Nursing care plan in (option D) is incorrect. The nursing care plan is a document that outlines the nursing diagnoses, goals, interventions, and evaluations related to the client's care. While medication administration may be a part of the nursing care plan, documenting a medication error in this location is not the standard practice. Incident reports are specifically designed for reporting and documenting errors or incidents that occur during client care.

This statement accurately reflects the client's own account of what happened, providing important information about the circumstances leading to the fall. Including the client's statement helps document the client's perspective and can contribute to a more comprehensive understanding of the event.
B. "The client fell because the assistive personnel did not place nonskid slippers on the client." This statement assigns blame to the assistive personnel without sufficient evidence. It is important to maintain objectivity and avoid making assumptions or assigning fault without proper investigation or documentation of facts.
C. "The client does not appear to have any injuries resulting from the fall." While it is important to assess the client for any injuries after a fall, documenting this information may be more appropriate in the client's assessment or nursing notes rather than in the specific documentation about the fall incident itself.
D. "An incident report has been completed and sent to risk management." While it is important to report falls and complete an incident report for quality improvement and risk management purposes, this information is more relevant to internal documentation and reporting processes rather than inclusion in the medical record for the client's care.