The tech is charting the patient’s response to pain medication they administered one hour ago. Which of the following descriptions should the tech use?
  1. “Pain decreased from an ‘8’ to a ‘3’ on the pain scale, less grimacing and able to move in bed.”
  2. “Patient states he is comfortable and denies nausea.”
  3. “Patient tolerated medication well.”
  4. “No evidence of pain.”
Explanation
Answer: A-The tech should document “Pain decreased from an ‘8’ to a ‘3’ on the pain scale, less grimacing and able to move in bed.” This description indicates both patient statements and evidence that the pain is under control. When documenting, the tech should try to use clear indications and examples rather than vague statements that could be misinterpreted.
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