A patient states that he or she is experiencing pain in the lower back.What is the best way for the nurse to document this subjective information?
A) "Seems back is hurting."
B) "States 'My lower back hurts.'"
C) "Grimaces when moving; I believe patient has lower back pain."
D) "Appears to be uncomfortable with lower back pain."

Question

Quizplus · Accepted Answer

The only subjective data included in a record are what the patient says.Write subjective information with quotation marks,using the patient's own words.For example,a patient's statement of "My lower back hurts" is subjective and acceptable documentation.Seems and appears should be avoided.A factual record contains descriptive,objective information about what you see,hear,feel,and smell,not the nurse's opinions.

A Patient States That He or She Is Experiencing Pain