The nurse is documenting a plan of care for a mental health patient. Which of the following principles should guide the nurse's documentation?
A) The nurse should include judgments regarding client data.
B) The nurse should note if an intervention was "tolerated well."
C) The nurse should include both objective and subjective data.
D) The nurse should use a medical model to guide the documentation process.
Ans: C
Feedback:
When documenting the nursing process, key components and principles include the following: nursing documentation becomes part of the client's permanent record; nurses document objective and subjective data; written documentation should be clear and legible; nurses should avoid including inferences or judgments regarding the data or the client in documentation; and nurses should avoid general statements such as "good," "fine," and "tolerated well." Instead, they use concrete and specific terms to describe data.
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