Which documentation entry is most appropriate after a patient reports hearing a voice telling them to self-harm?
Correct answer: B. Patient reports hearing a voice telling them to self-harm
- A. Patient is attention-seeking and manipulative
- B. Patient reports hearing a voice telling them to self-harm
- C. Patient is probably experiencing a psychotic disorder
- D. Patient has bizarre behavior and poor personality traits
Explanation
Mental health documentation should use objective, specific words and should record the patient’s own report in quotation marks when appropriate. Labels, assumptions, and judgemental terms are not suitable substitutes for observed or reported data.
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About Foundations of Mental Health Nursing
Mental health nursing covers concepts of normal and abnormal behavior, major psychological theories, psychiatric assessment, the nurse’s therapeutic role, and the use of a safe therapeutic milieu. It also includes confidentiality, informed consent, patient rights, ethical decision-making, legal responsibilities, and individualized nursing care planning.
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