A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (ISBARR) on a client. Which of the following information should be included in the situation component?

Choice A reason: This statement is correct because the nurse should use objective terminology when documenting the occurrence. Objective terminology means using factual, unbiased, and verifiable information, such as the date, time, location, witnesses, and events of the occurrence. The nurse should avoid using subjective, opinionated, or judgmental language, such as blaming, criticizing, or speculating about the occurrence.
Choice B reason: This statement is incorrect because the nurse should not wait at least 12 hours to report the occurrence. The nurse should report the occurrence as soon as possible, preferably within an hour of the incident. The nurse should also notify the appropriate personnel, such as the charge nurse, the provider, and the risk manager. Delaying the report may compromise the client's safety and wellbeing, and the accuracy and completeness of the documentation.
Choice C reason: This statement is incorrect because the nurse should not omit the name of the individuals involved in the occurrence. The nurse should include the name of the client, the staff, and any other relevant parties, such as family members or visitors. The nurse should also document the role and actions of each individual, and their response to the occurrence. Omitting the name of the individuals may affect the accountability and follow-up of the occurrence.
Choice D reason: This statement is incorrect because the nurse should not document completion of the report in the client’s medical record. The nurse should document the occurrence report separately from the client’s medical record, and follow the facility's policy and procedure for filing and storing the report. The nurse should also document the occurrence in the client’s medical record, but only the facts and the nursing actions, not the details or the existence of the report. Documenting completion of the report in the client’s medical record may expose the facility to legal liability or litigation.

Choice A reason: The use of social media is included in the COE. According to the ICN Code of Ethics for Nurses, nurses should use social media responsibly and ethically, respecting the privacy and confidentiality of patients, colleagues, and employers. Nurses should also avoid posting any information that could harm the reputation of the profession or the health care organization.
Choice B reason: Student nurses are held accountable to the COE. According to the ANA Code of Ethics for Nurses, student nurses are expected to uphold the same ethical standards as registered nurses, as they are members of the profession and the public trust. Student nurses should also adhere to the academic policies and regulations of their educational institutions.
Choice C reason: Criteria for obtaining licensure is not included in the COE. The COE is not a legal document, but a guide for ethical nursing practice and decision-making. Criteria for obtaining licensure is determined by the regulatory bodies of each country or state, and may vary depending on the level and scope of practice.
Choice D reason: Professional expectations are included in the COE. The COE defines and guides the ethical values, responsibilities, and accountabilities of nurses in all settings, roles, and domains of practice. The COE also provides a framework for self-evaluation, peer review, and quality improvement.