Your patient is admitted with a serious injury of the left hip after a fall at home. She is crying with severe pain in her left hip and leg. Which nursing diagnosis would apply to this patient's immediate needs?

A. Incident reports must be recorded in the nurse's notes: Incident reports should not be recorded in the patient’s chart. They are used internally to improve patient safety and should be kept separate from the medical record.

B. Institutions are only reimbursed for patient care that is documented: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as documentation serves as proof that care was provided.

C. Document only when not successful: Documentation should be comprehensive, including both successful and unsuccessful interventions, to provide a full picture of patient care.

D. The patient record is a complete picture of individualized problems, treatments, and responses to treatments: A patient's medical record includes their health status, nursing interventions, and responses, making it a complete reference for continuity of care.

A. Every facility should have an approved abbreviations list. Hospitals and healthcare settings maintain a list of approved abbreviations to ensure consistency and prevent misinterpretation.

B. Creating abbreviations saves time for the person reading the chart: Unapproved abbreviations can lead to confusion and errors, potentially harming the patient.

C. Writing out questionable abbreviations could make a jury think you're hiding something: Avoiding abbreviations improves clarity, and using full words is preferred in legal documentation.

D. Abbreviating drug names and dosages helps reduce medication errors: Abbreviating drug names can cause dangerous medication errors (e.g., MS can mean morphine sulfate or magnesium sulfate). The Joint Commission prohibits certain abbreviations.