During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

A. CNA (Certified Nursing Assistant): CNAs assist with basic patient care (e.g., hygiene, vital signs) but do not perform assessments or make nursing diagnoses.

B. Technician: Technicians perform specific tasks (e.g., drawing blood, ECGs) but do not analyze patient data for diagnosis.

C. RN (Registered Nurse): The RN is responsible for analyzing and interpreting data, identifying nursing diagnoses, and developing the care plan.

D. LPN/LVN (Licensed Practical/Vocational Nurse): LPNs/LVNs can collect data but cannot make a nursing diagnosis, which is the RN’s role.

A. Interview and physical examination: The two primary methods of data collection in nursing are:

• Interview (subjective data: patient history, symptoms, concerns)

• Physical examination (objective data: vital signs, assessment findings)

B. Review of the doctor's orders and the Kardex: This provides supplementary data but does not directly collect patient information.

C. Written report by patient and family: This may provide valuable subjective data but is not a primary method of data collection.

D. Review of the chart and the nurse’s notes: This is reviewing existing documentation, not actively collecting data.