Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

A. Incident reports must be recorded in the nurse's notes: Incident reports should not be recorded in the patient’s chart. They are used internally to improve patient safety and should be kept separate from the medical record.

B. Institutions are only reimbursed for patient care that is documented: Insurance companies and government programs (e.g., Medicare, Medicaid) only reimburse for care that is documented, as documentation serves as proof that care was provided.

C. Document only when not successful: Documentation should be comprehensive, including both successful and unsuccessful interventions, to provide a full picture of patient care.

D. The patient record is a complete picture of individualized problems, treatments, and responses to treatments: A patient's medical record includes their health status, nursing interventions, and responses, making it a complete reference for continuity of care.

A. The provider’s observed data: Objective data includes what the nurse or provider directly observes and measures, such as vital signs, lab results, and physical exam findings.

B. All of the answers are correct: Only option A is correct because C and D do not define objective data.

C. The patient’s perception of provided data: The patient’s perception is subjective data, not objective.

D. The patient’s request for information: A request for information is neither assessment data nor an objective finding.