Recording a complaint in the resident's words
Question
A resident tells the nursing assistant, "My stomach hurts." Which entry is the best way to document this?
Answer
A. The resident stated, "My stomach hurts."
Rationale
What a resident says is subjective data and cannot be verified by others, so it is recorded exactly as spoken and in quotation marks. The nursing assistant also reports it to the nurse and leaves the interpretation to the nurse.
Sources
Sources marked “Adapted from” are licensed under CC BY 4.0. We changed the material: its facts are rewritten into an original question, answer options and rationale. The original authors and publishers do not endorse SwipeExam.
- Adapted from Open RN Nursing Assistant: Chapter 7: Demonstrate Reporting and Documentation of Client Data
- Adapted from Open RN Nursing Skills, 2nd edition: Chapter 1 General Survey
- Adapted from Open RN Nursing Assistant: Chapter 1: Communicate Professionally Within a Health Care Setting
- Adapted from Open RN Nursing: Mental Health and Community Concepts, 2nd edition: TRAUMA, ABUSE, AND VIOLENCE
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