Nursing Notes 1905: Unlicensed assistive personnel (UAP) sta…

Questions

Nursing Nоtes 1905: Unlicensed аssistive persоnnel (UAP) stаtes thаt they fоund client on the floor in a pool of fluid and the client stated, "I tried to get to the bathroom and fell." The client probably fell because they day shift nurse refused to answer the call light so close to the end of their shift. Client assessed and no injuries found. Assisted to the bathroom and back to bed. UAP gave client a bath. Client resting comfortably in bed. Call light within reach. Health care provider notified.1945: Client denies pain and discomfort. Continue to monitor.2100: Assisted client to bedside commode. Client voided 300 mL clear urine. Client was thirsty and drank a cup of water. Assisted back to bed. Resting comfortably. Vital Signs Time Blood Pressure Heart Rate Respiratory Rate Temperature SpO2 1800 125/80 89 16 98.9 F37.2 C 96% RA 1905 118/74 95 18 98.9 F37.2 C 96% RA Intake and Output 1000 1300 1800         2100 Oral Intake 100 mL 250 mL 250 mL 250 mL Urine Output -350 mL -300 mL Bowel Movement x 1             Question:  A team of clinical nurse specialists conducts audits of electronic health records (EHRs). When reviewing this client's EHR, what piece of documentation do the nurses find most concerning?