Which entry is the most objective nursing documentation?
Correct answer: A. Patient says, "I feel dizzy" after standing.
- A. Patient says, "I feel dizzy" after standing.
- B. Patient appears anxious and looks very unwell.
- C. Patient is difficult and refuses all treatment.
- D. Patient seems uncomfortable during the procedure.
Explanation
The statement in option A records the patient’s own words, making it subjective data documented accurately. The other options contain vague observations or judgments that need specific measurable details.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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