A new graduate nurse is working with an experienced nurse to chart assessment findings. The new nurse notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM
The experienced nurse asks the new nurse what may be going on here. What is the best explanation for this statement?
a. Data on the chart can sometimes be documented in a biased manner.
b. Data on the chart changes as the patient's condition changes.
c. Data on the chart is usually accurate and can be verified from the patient.
d. Reading the chart is not a wise use of time as this can be time consuming and tedious.
ANS: A
It is important that the nurse records only what is assessed, without adding judgments or interpretations to the record. Data do indeed change (and need to be charted) as the patient's condition changes, but this would not be the best answer to this question. Assessment data may at times be difficult to obtain, but that would not occur often enough to warrant a warning about the difficulty in charting it. Also, obtaining data is clearly a different activity from charting it. Charting can be time consuming and tedious, but this is not the most complete answer to this question.
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