The client states: "I really don't want anyone to visit me who has not been cleared by me first." If utilizing SOAP format, this statement would be documented under which category?
1. Subjective data
2. Objective data
3. Assessment
4. Planning
Correct Answer: 1
Rationale 1: Subjective data consist of information obtained from what the client says. When possible, the nurse quotes the client's words; otherwise, they are summarized.
Rationale 2: Objective data consist of information that is measured or observed.
Rationale 3: Assessment is the interpretation or conclusion drawn about the subjective and objective data. This is the area where the problems are documented initially. Then the client's condition and level of progress are subsequently described.
Rationale 4: Planning is the care designed to resolve the problem.
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