A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?

A) Assessment:
Assessment involves gathering and analyzing data about the client’s health status and needs. While gathering information from the social worker and physical therapist may be part of the assessment process, the actual collaborative work in preparing the discharge plan is more aligned with the planning phase of the nursing process.

B) Planning:
Planning is the correct answer because it involves formulating goals, interventions, and expected outcomes for the client’s care, including discharge projections. In this case, the nurse, social worker, and physical therapist are working together to develop a comprehensive discharge plan tailored to the client’s needs, which is a key part of the planning phase.

C) Evaluation:
Evaluation occurs after interventions are implemented to assess whether the goals have been met and the outcomes achieved. Since the nurse is still in the process of preparing the discharge plan, evaluation has not yet occurred.

D) Analysis:
Analysis is the process of interpreting assessment data to identify problems or needs. While analysis is part of the assessment phase, it does not describe the collaborative action of creating a discharge plan, which is clearly a planning task.

Choice D:

The client seems to be more comfortable performing self-administration of insulin: The use of the term “seems” introduces subjectivity, which weakens the clarity and objectivity of the documentation. It’s better to describe specific observations or objective findings. For instance, instead of using “seems,” the nurse could note how the client demonstrated confidence or performed the task with ease, providing concrete evidence of improvement.