A nurse assessed a patient who reluctantly participated in activities, answered questions with minimal responses, and rarely made eye contact. What information should be included when documenting the assessment? Select all that apply
a. The patient was uncooperative
b. The patient's subjective responses
c. Only data obtained from the patient's verbal responses
d. A description of the patient's behavior during the interview
e. Analysis of why the patient was unresponsive during the interview
ANS: B, D
Both content and process of the interview should be documented. Providing only the patient's verbal responses would create a skewed picture of the patient. Writing that the patient was uncooperative is subjectively worded. An objective description of patient behavior would be preferable. Analysis of the reasons for the patient's behavior would be speculation, which is inappropriate.
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