Which of the following is the best example of objective charting?
A)"The patient states that he has been having severe chest discomfort."
B)"The patient is lying in bed and seems to be in considerable pain."
C)"The patient appears to be pale and diaphoretic and complains of nausea."
D)"The patient's skin is ashen and respiratory rate is 32 and labored."

Question

Quizplus · Accepted Answer

A record or report contains descriptive,objective information about what you see,hear,feel,and smell.An objective description is the result of direct observation and measurement,such as "respiratory rate 20 and unlabored." Objective documentation should include your observations of patient behavior.For example,objective signs of pain include increased pulse rate,increased respiration,diaphoresis,and guarding of a body part.The only subjective data included in a record are what the patient actually verbalizes.Write subjective information with quotation marks,using the patient's exact words whenever possible.For example,you record,"Patient states,'my stomach hurts.'" Avoid terms such as appears,seems,and apparently,which are often subject to interpretation.For example,the description "the patient seems to be in pain" does not accurately communicate the facts to another caregiver.The phrase seems is not supported by any objective facts.

Which of the Following Is the Best Example of Objective