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April 2004, Volume 34 Number 4 , p 20 - 20




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    I'm a recent graduate. Last week, I made the following entry into my patient's chart : Patient has good pedal pulses and moves legs and feet well . My nurse-manager told me this entry wasn't specific enough, but she didn't explain. I'd like to improve my charting skills. Can you help ?—J.S., TENN.

    Figure. No caption available. Many new nurses make the mistake of charting subjective, rather than objective or factual, information. Subjective information, such as patient has good pedal pulses , might be questioned in court because it reflects your opinion about a patient's condition, not your objective observations.

    That's not to say that your patient's subjective statements are off-limits. You should include pertinent observations and information he provides about his own condition. For example, “My foot hurts” is a subjective comment you'd want to chart—and ...

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