a question about documentation

on a night shift, a pt c/o nausea. I assessed pt and documented as following:

pt c/o nausea. No emesis, no palpitation or sweating. Bowel sound normal in all quads. Water offered. will continue to monitor.

is the above documentation sufficient?

From documentation point of view, if the pt suffered MI shortly after the night shift, is the documentation sufficient to prove standard nursing care? ( pt is ok, just trying to improve my documentation. thanks)
Did you do anything to relieve the nausea, either by using a prn order or contacting the provider for one? And I'm not sure I would be offering anything p.o. to someone who is currently nauseated.

Quote from treeyeon a night shift, a pt c/o nausea. I assessed pt and documented as following: pt c/o nausea. No emesis, no palpitation or sweating. Bowel sound normal in all quads. Water offered. will continue to monitor.is the above documentation sufficient? From documentation point of view, if the pt suffered MI shortly after the night shift, is the documentation sufficient to prove standard nursing care? ( pt is ok, just trying to improve my documentation. thanks)

The patient's underlying diagnosis & problems would dictate the type of nursing interventions and degree of urgency. Nausea in a pt with cardiac hx would be treated entirely differently than nausea in a CRF or fresh post-op patient. Always make sure that your critical thinking is evident in your documentation. Assessment should include most likely underlying causes, in order of priority.... ex: for cardiac pt, you would do complete VS & probably get an EKG; for CRF, you may want to look at lytes, for post-op, make sure NGT is patent & working.... etc.