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Reporting, Documentation & The Care Plan

Which description of a skin finding is the most objective for charting and reporting?

  • A.The resident's skin looks terrible on the back today
  • B.The resident probably has an infection on the heel now
  • C.The sore must have been caused by poor care last week
  • D.There is a reddened area about two inches wide on the left heel
Correct answer

D. There is a reddened area about two inches wide on the left heel

Why

An objective description states location, size, and appearance that can be observed and measured. Judgments about how terrible it looks, guesses about infection, or claims about cause are opinions or diagnoses, not observations.

Content outline: Role of the Nurse Aide - Reporting: Observations · From the Role of the Nurse Aide practice bank (RA-119).

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