A nurse is discussing the advantages and challenges of electronic health records (EHRS) with a newly licensed nurse.
Which of the following should the nurse include as an advantage?

Answer and explanation

The correct answer is Choice B.

Choice A rationale

Speculating about the cause of the fall ("probably urinated on the floor") is unprofessional and lacks factual basis. Charting should be objective and based on observed facts, not assumptions.

Choice B rationale

Documenting objective observations, such as finding the patient on the floor with the urinal nearby, provides a factual account of the incident without making assumptions or assigning blame. This allows for a more accurate analysis of potential contributing factors.

Choice C rationale

Commenting on the nurse assistant's work habits ("always took her time") is subjective, irrelevant to the fall incident itself, and unprofessional. Charting should focus on the patient and the event.

Choice D rationale

Describing the patient as "grouchy and inappropriate" is judgmental, subjective, and does not contribute to an understanding of the fall. Such personal opinions are inappropriate for medical documentation.

Choice A rationale

A medical diagnosis identifies a specific disease or pathological process based on signs, symptoms, diagnostic tests, and medical history. It focuses on the disease itself and its etiology, which differs from evaluating a patient's response to health issues.

Choice B rationale

A nursing diagnosis is a clinical judgment concerning a human response to health conditions, life processes, or vulnerability for that response by an individual, family, group, or community. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

Choice C rationale

A collaborative problem is a potential or actual physiological complication that nurses monitor to detect the onset of changes in a patient’s status. These problems require both nurse-prescribed and physician-prescribed interventions, focusing on managing potential complications rather than the response itself.

Choice D rationale

A physician's order is a directive from a medical doctor or other legally recognized healthcare provider that outlines specific treatments, medications, tests, or other interventions for a patient. It guides medical care, not the identification of patient responses.