A student nurse is responsible for assessing a patient, who is abrupt and requests that the assessment be done later by a nurse. As the student nurse charts the interaction, which statement is the best way to document what happened?
a. Appears to be in pain as evidenced by grouchy behavior
b. Behavior is inappropriate, requests registered nurse do the assessment
c. States, "I want a registered nurse to do my assessment"
d. Is grumpy, registered nurse notified
C
When a nurse collects objective data, he or she should apply critical thinking intellectual standards (e.g., clear, precise, and consistent). Nurses do not include personal interpretive statements. The timely, thorough, and accurate communication of facts is necessary to ensure continuity and appropriateness of patient care. If you do not report or record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient. Grouchy, inappropriate, and grumpy are personal interpretive statements and should be avoided.
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