A nurse is writing documentation after completing care. Which statement reflects good documentation practice?

1. “Patient seemed upset during care; I think this was maybe due to anxiety.”
2. “Patient cried throughout care but finally accepted the procedure in the end.”
3. “Patient refused the medication, which was probably caused by ongoing pain.”
4. “Administered 2 mg morphine IV at 1400 h per pain protocol; reassessed at 1430 h, pain 2/10.”

Practice all 20 Documentation and Hand-Off Communication questions