How should a nurse appropriately document a conversation with a surgeon regarding a change in a patient’s incision?

The most effective documentation in this scenario includes specific details about the communication with the surgeon, including the exact issue that prompted the conversation and the nature of the findings. Documenting that "Dr. Oakman contacted about new area of bright red erythema" provides clarity about what was observed (the new area of bright red erythema) and indicates that this was communicated directly to the physician involved in the patient's care.

This level of detail is essential in nursing documentation, as it not only reflects the nurse’s assessment but also establishes a clear account of communication regarding the patient’s condition. It conveys vital information for continuity of care, ensuring that all members of the healthcare team have access to pertinent information regarding the patient's status and can act accordingly. This approach also minimizes ambiguity in documentation, enhancing accountability and aiding in effective patient management.