Best Documentation Practice for a Client with Dementia
Which documentation by the nurse best follows documentation guidelines?
A. "Patient was confused today."
B. "Patient exhibited aggressive behavior."
C. "Patient wandered around the unit."
D. "Patient attempted to elope; redirected to the activity room."
Answer:
The best documentation option for a nurse caring for a client with dementia is "Patient attempted to elope; redirected to the activity room (option D)." It is the most specific and informative, adhering to professional documentation standards of being clear, objective, and action-oriented.
Explanation:
The documentation that best follows guidelines when caring for a client with dementia is "Patient attempted to elope; redirected to the activity room." This statement is the most descriptive and factual among the options, providing specific, measurable information about the patient's behavior and the action taken by the nurse. Good documentation should be objective, clear, and detailed to accurately reflect the care provided and support continuity of care.
Terms such as "confused" and "aggressive behavior" are subjective and do not describe specific incidents or actions. Moreover, saying the patient "wandered around the unit" is less informative than option D because it lacks detail on how the behavior was addressed. Proper guidelines for documentation in dementia care involve using objective language, recording specific behaviors, and noting any interventions made by healthcare staff.
Hence, the answer is option D.