Which of the following is a nursing diagnosis?

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."

A. owned by the patient, who has a right to see the data any time he/she wishes
The healthcare facility owns the physical record; the patient has a right to access their information, but not ownership.

B. concise, legal records of all care given and responses
Health records must be clear, accurate, and complete because they serve as legal documentation of care provided and the patient’s response.

C. confidential information and cannot be taken to court
While confidential, they can be subpoenaed and used in court if relevant.

D. not used by anyone else but the direct care providers
Health records are also used by legal teams, researchers (with consent), auditors, and regulatory agencies.