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Kiana Jordan
on Oct 18, 2024

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The nurse documents in the progress notes: "Admitted to emergency department accompanied by wife.Patient is alert and oriented,blood pressure is 120/80 mm Hg,and pulse is 80 beats/min.The patient is anxious.He becomes nervous and when asked about his smoking history." Which statement from the nurse's note is the best example of an inference?

A) Blood pressure reading 120/80 mm Hg
B) Patient is accompanied by wife.
C) Patient has a history of smoking.
D) The patient is anxious.

Progress Notes

Written documentation in a patient's medical record that outlines the healthcare services, treatments, interventions, and conditions of a patient over time.

Inference

The process of drawing logical conclusions from available information or evidence.

Smoking History

A record of an individual's smoking behavior over time, crucial for assessing health risks.

  • Distinguish between objective data and nurse inferences in documentation.
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Sevak YeranosyanOct 23, 2024
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