A nurse is assisting with preparing an educational session about The Joint Commission (TJC). Which of the following information should the nurse include?

Choice A reason: This statement is false and should not be included in the teaching. Placing the client on 12hour observation is not enough to ensure the client's safety, as the client may still attempt suicide when the nurse is not watching. The client should be placed on continuous observation, preferably one-to-one, until the risk of suicide is reduced.

Choice B reason: This statement is false and should not be included in the teaching. Encouraging visitors to bring items to the client is not advisable, as some items may pose a potential danger to the client, such as sharp objects, medications, or alcohol. The nurse should inspect and limit the items that the client and the visitors have access to, and remove any items that could be used for self-harm.

Choice C reason: This statement is false and should not be included in the teaching. Encouraging visitors for the client at any time is not appropriate, as some visitors may have a negative impact on the client, such as those who are abusive, judgmental, or unsupportive. The nurse should screen and monitor the visitors, and allow only those who are helpful and respectful to the client.

Choice D reason: This statement is true and should be included in the teaching. Removing harmful objects from the client's room is a priority action that the nurse should take to prevent the client from harming themselves. The nurse should search the client's room and belongings, and remove any objects that could be used for suicide, such as knives, scissors, razors, belts, cords, or plastic bags.

Choice A reason: SOAP documentation is not the correct method for documenting only unexpected findings. SOAP documentation requires the nurse to document both normal and abnormal findings, as well as the plan of care for the client.

Choice B reason: Problem oriented medical record (POMR) is not the correct method for documenting only unexpected findings. POMR is a method that organizes the documentation around the client's problems, rather than the source of data. It consists of four components: database, problem list, plan, and progress notes.

Choice C reason: Focus charting (DAR) is not the correct method for documenting only unexpected findings. Focus charting is a method that uses the nursing process and the client's perspective to document the client's care. It consists of three components: data, action, and response.

Choice D reason: Charting by exception (CBE) is the correct method for documenting only unexpected findings. CBE is a method that assumes that all standards of care are met unless otherwise documented. It allows the nurse to document only significant or abnormal findings, such as changes in the client's condition, interventions, or outcomes.