A nursing instructor has instructed a student nurse to document objectively. The student nurse demonstrates understanding when documenting
a. "Patient is noncompliant."
b. "Patient is drunk, confused, and uncooperative."
c. "Patient and family are nasty, abrasive, and difficult."
d. "Odor of alcohol on breath; refuses to stay in assigned room."
ANS: D
All charting must be specific, objective, and complete. One should avoid subjective comments and personal judgments in charting. The remaining options are examples of subjective charting. Listing facts such as the smell of alcohol and the behavior of the patient is an example of objective charting.
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