Examples most appropriate for clinical record entry


Question: Which of the following documentation examples is the most appropriate clinical record entry? Found resident without sacral dressing. Passed on to day shift. Not an 11/7 dressing. Found resident without sacral dressing again. Wrote up day shift treatment nurse. Upon assessment, sacral dressing not in place. Replaced dressing per MD order for wound care. See wound flowsheet for details of wound description and treatment. MD refused to change wound dressing order to an enzymatic debrider, so it's still got slough all over it and now it's starting to turn black

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Other Subject: Examples most appropriate for clinical record entry
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