A nurse has just admitted a patient with a medical diagnosis of Rule out myocardial infarction. When completing the paperwork the nurse needs to record:
A. an interpretation of patient behavior.
B. objective data that are observed.
C. lengthy entries using lay terminology.
D. abbreviations familiar to the nurse.
B
Nurses should only include descriptive, objective information about what they see, hear, feel, and smell. Entries should be precise and accurate. Nurses must only use acceptable abbreviations identified by their institution. The Joint Commission has strict regulations regarding the use of abbreviations.
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