The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.

B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.

C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.

D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.

A. Wait until the end of the shift to document: Documentation should be done promptly after care is provided to ensure accuracy and completeness. Delaying documentation increases the risk of errors or omissions.

B. Cover errors with correction fluid, and write in the correct information: Errors should never be covered with correction fluid. Instead, a single line should be drawn through the mistake, followed by the correction and the nurse’s initials.

C. Use as many abbreviations as possible to save space: Only approved abbreviations should be used to avoid misinterpretation and increase clarity. Overuse of abbreviations can lead to confusion.

D. Document objective data, leaving out opinions: Documentation should be factual and objective (e.g., "Patient grimaced when moving" instead of "Patient appears to be in pain"). Subjective or opinion-based language should be avoided.

E. The date and time should be included with each entry: Every entry must have a date and time to provide an accurate timeline of care, ensuring legal protection and continuity of care.