Based on the sample nursing documentation

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Reference no: EM133833305

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Based on the sample nursing documentation, state the documentation in a different manner, as straightforward as possible but still have the relevant information. Patient is a pleasant 85 year old female with recent right sided CVA. Prefers to be called Libby. Patient oriented to name. Patient aware she is not home but disoriented to place, time, date. Patient has history of HTN and tachycardia and takes trandolapril 4mg Po daily. Patient is reporting 6/10 sharp pain to lower back worsening over last hour and with bending action. Denies radiating pain. BP x/x, Resp x/min easy and regular, Pulse xxbpm regular, SPO2 x% on room air, Temp. X degrees C oral. Patient experiencing onset low back pain, vitals with normal range. Writer will administer Tylenol 500mg as per patient's request for pain relief. Will notify Dr. X of back pain and continue to monitor pain status.

Reference no: EM133833305

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