When asked, an alert and oriented 44-year-old man with a history of high blood pressure reports that he called for help because my chest is hurting. He is diaphoretic and nauseated, has a pulse of 88 and a BP of 156/92, and says that his pain feels just like my heart attack two years ago. Based on this information, how would you document his chief complaint on the patient care report?
a. My chest is hurting.
b. Possible heart attack
c. Myocardial infarction
d. Chest pain with hypertension
Question 2
When writing a prehospital care report, you accidentally document a laceration as being on the left side of a patient's face when it was actually on the right side of the face. In addition to putting your initials and current date/time next to your correction, you would change your documentation in which of the following ways?
a. Color over the word left with black ink and write the word right next to it.
b. Write the word error through the word left and then write the word right next to it.
c. Use correction fluid to cover the word left and write the word right next to it.
d. Draw a single line through the word left and write the word right next to it.
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History
Nursing Care Plan Process: Client with High Blood Lipid Levels