A nurse has received change-of-shift report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning"

Question

How could the charting entry be best improved? A) The entry should include clearer descriptions of the client's mood and behavior
B) The entry should avoid mentioning cognitive or psychosocial issues
C) The entry should list the specific reasons that the client was upset
D) The entry should specify the subsequent interventions that were performed

Answer 1

A
Feedback:
Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so that a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.