ApplicationIntermediate
Which notation is most appropriate for documenting a patient's goal regarding ambulation in the nursing chart?
The most appropriate notation for documenting a patient's goal regarding ambulation is: "Goal met; patient ambulated three times in the hallway without SOB."
Key points
- Documentation must accurately convey information to other care providers.
- Patient goals should be specific and measurable, such as ambulating a certain number of times without shortness of breath.
- Evaluation statements should reflect whether the goals were met, partially met, or unmet.
Source:Fundamentals of Nursing: Active Learning for Collaborative Practice· Documentation, Electronic Health Records, and Reporting· p. 434–446
Fundamentals of Nursing: Active Learning for Collaborative Practice
Barbara L Yoost & Lynne R Crawford
2E