A nurse is planning to reinforce discharge teaching with a client who has hearing loss.
Which action should the nurse plan to take?

Choice A rationale

Evaluation is the final step of the nursing process, where the nurse determines the client's progress toward achieving the established goals and outcomes. This involves comparing the client's current status and responses to the criteria set during the planning phase, and then modifying the care plan as necessary, which occurs after goal formulation.

Choice B rationale

Data collection (Assessment) is the initial step of the nursing process, involving the systematic and continuous gathering of subjective and objective information about the client. This foundational step precedes the identification of problems and the formulation of goals, as the data collected is used to inform and drive the goals developed later in the process.

Choice C rationale

Implementation is the action phase where the nurse performs the planned interventions to achieve the established goals. This step occurs after the planning phase where the goals are formulated, as the goals provide the specific direction and purpose for the nursing actions and interventions carried out by the nurse.

Choice D rationale

Planning is the step where the nurse, in collaboration with the client and other healthcare providers, formulates realistic, client-centered goals and expected outcomes. This step uses the data from the assessment to prioritize needs and then sets specific, measurable criteria for a positive outcome, directly aligning with the scenario described.

Choice A rationale

Documentation must be organized (logically structured for clarity) and timely (contemporaneously recorded during or immediately following the event) to ensure accurate legal and clinical correlation. Timeliness is crucial as it reduces recall bias, enhancing the document's scientific reliability and legal credibility by linking the recorded data precisely to the time of care delivery.

Choice B rationale

Accuracy means documenting facts and observations without speculation, ensuring data integrity. Completeness requires including all relevant details, patient responses, and communications. This dual standard ensures the medical record is a scientifically and legally sound chronological account, reflecting the professional standard of care provided and forming a reliable basis for interprofessional communication.

Choice C rationale

A nurse's interpretation is a subjective opinion and should be avoided in legal documentation, which must focus on objective, observable, and measurable data. Conclusions or interpretations about the client's state should be reserved for the nursing process analysis (e.g., a formal nursing diagnosis), not the basic descriptive charting, to maintain factual integrity.

Choice D rationale

Client medical records contain Protected Health Information (PHI) and are governed by strict federal privacy laws, such as HIPAA. Information can only be shared on a need-to-know basis for treatment, payment, or healthcare operations, not with all employees. Unauthorized sharing is a violation of the client's privacy rights and is illegal.

Choice E rationale

The medical record is a legal document admissible in court, reflecting the quality and nature of care delivered. As an official, contemporaneous business record of the healthcare facility, it serves as the primary scientific and legal evidence in malpractice lawsuits, regulatory audits, and quality reviews, hence the strict standards for accuracy and completeness.