Cody is going to document in Mr. Brown's medical record.
Which of the following is appropriate to document? (Case #1)

Choice A rationale

Subjective opinions like "pleasant to care for" lack specific, objective data about the patient's condition or care provided. Medical documentation should focus on factual observations and interventions related to the patient's health status.

Choice B rationale

"Voiding without difficulty" is a relevant observation regarding the patient's urinary function. However, it lacks specific details such as the amount, color, or clarity of the urine, which are important for a comprehensive assessment.

Choice C rationale

This statement provides specific and objective information about the patient's pain experience. It includes the patient's self-reported pain level (6/10), the location of the pain (left temporal area), and a relevant negative finding (no relief with positioning), all contributing to a clear understanding of the patient's condition.

Choice D rationale

"Onsite looks good" is vague and lacks specific details about the condition of a particular site (e.g., surgical wound, IV insertion site). Effective documentation requires descriptive terms regarding appearance, such as color, presence of drainage, swelling, or redness.

Choice A rationale

Centralized management involves top-down decision-making, where the nurse manager holds authority for policies, reviews, and disciplinary actions. This structure concentrates power and control at the managerial level, limiting staff input and autonomy in shaping unit operations and standards of practice.

Choice B rationale

Regularly monitoring patient care by making rounds is a supervisory function, ensuring adherence to established protocols and identifying immediate issues. While important for quality assurance, it doesn't inherently decentralize decision-making or empower staff in a collaborative manner.

Choice C rationale

Decentralized management empowers staff at lower levels to participate in decision-making processes. When staff nurses collaborate with the manager to review care options and implement preventive strategies, it distributes authority and fosters a sense of ownership and shared responsibility for patient outcomes.

Choice D rationale

Conducting regular staff meetings to disseminate information about new equipment and policies is a communication strategy that ensures staff are informed. However, it does not necessarily involve staff in the formulation or decision-making processes related to these changes, maintaining a more centralized approach.