The student nurse prepares to document in the nursing note, “Patient is in bad mood today.” The preceptor corrects the student nurse to document which statement instead?

Patient refuses to eat dinner, and says, “Get lost”. Communicating patient’s condition and progress is vital in obtaining baseline data for the plan of care and in ensuring continuity of care. It is not appropriate for the nurse to characterize or generalize patient’s behavior. Instead of using ‘bad mood’ description, the nurse can directly quote patient’s remarks or response and actual actions. Avoiding judgment helps in establishing baseline data and provides more credibility for medical or legal use. The nurse does not speculate on the cause of the patient’s mood by documenting that the patient seems to have broken up with this girlfriend. Stating the patient is not his usual self is not detailed enough. Documenting the patient is rude is not objective or professional and should be avoided.

The student nurse prepares to document in the nursing note, &ldqu...

Category: Management of Care
Difficulty: 3

Topics: Communication & Documentation

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