Documentation is necessary for the evaluation of patient care and is a part of which phase of the nursing process? (select all that apply)
assessment
implementation
planning
evaluation
Correct Answer : A,B,D
A. Assessment
During the assessment phase, documentation of data (subjective and objective) is essential for forming the diagnosis.
B. Implementation
Nurses must document the interventions they perform during the implementation phase, including teaching, medications, and care given.
C. Planning
While planning involves developing goals and interventions, documentation is less emphasized here than in other phases.
D. Evaluation
In the evaluation phase, documentation of patient responses and progress toward outcomes is critical to determine the plan’s effectiveness.
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Correct Answer is D
Explanation
A. Planning:
In the planning phase, nurses set the desired outcomes, but do not evaluate them yet.
B. Assessment:
Assessment involves gathering data to form diagnoses, not reviewing outcomes.
C. Implementation:
This step involves carrying out the plan of care, not analyzing whether outcomes have been met.
D. Evaluation:
This is the correct step where the nurse examines whether the patient goals/outcomes have been achieved and determines the effectiveness of interventions.
Correct Answer is C
Explanation
A. "Patient's condition much better today than yesterday."
This is vague and subjective. Good charting requires specific and measurable observations.
B. "Lump diminished."
This is imprecise. The size and location should be described objectively (e.g., "Lump decreased in size from 3 cm to 2 cm").
C. The patient states, "It feels like a knife stabbing me."
This is an exact, verbatim quote that accurately captures the patient’s subjective report. It’s clear, specific, and useful.
D. "No complaints of pain or discomfort."
While this may be accurate, it lacks supporting data (e.g., pain scale rating). A more precise entry would state, "Denies pain; pain scale 0/10."
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