A nurse is documenting in a client's information using the subjective, objective, assessment, and plan (SOAP) charting model.
Which of the following should be included in the subjective data?

Choice A rationale

While documentation can be reviewed by providers, its primary purpose is not to monitor nurses' performance. Monitoring occurs through various quality assurance processes, and documentation serves a broader range of functions beyond individual nurse oversight.

Choice B rationale

Documentation acts as a central communication hub for all members of the healthcare team, including physicians, nurses, therapists, and other specialists. It ensures continuity of care by providing a shared understanding of the client's condition, treatments, and responses, facilitating informed decision-making and collaboration.

Choice C rationale

Although documentation can be used for audits, such as financial or quality audits, this is not its primary purpose. The main goal of documentation is to provide a comprehensive record of patient care for effective communication and continuity.

Choice D rationale

While accurate documentation supports billing and reimbursement processes from various payers, including government entities, this is a secondary outcome. The primary aim of documentation is to ensure high-quality patient care through clear and comprehensive information sharing.

Choice A rationale

Increased technology awareness might be a consequence of EHR implementation, but it is not a primary advantage in terms of direct impact on patient care or healthcare delivery efficiency. The focus is on leveraging technology for improved outcomes.

Choice B rationale

EHRs facilitate seamless information sharing among healthcare providers, reducing reliance on paper-based records and improving coordination of care. This enhanced communication can lead to better-informed decision-making, reduced errors, and improved patient safety and outcomes.

Choice C rationale

The need for frequent technology updates can be a challenge associated with EHRs, requiring ongoing investment of time and resources for maintenance and training. This is a potential drawback rather than an advantage of electronic systems.

Choice D rationale

Required system changes, such as upgrades or modifications, can be disruptive and demand significant effort from healthcare organizations. While necessary for maintaining system functionality, they are not considered an inherent advantage of using EHRs.