Which of the following statements written by the nurse should be documented in the subjective findings of the patient record?


•Subjective documentation includes that which the patient states or describes, including a stated pain level or a report that the abdomen feels tender/uncomfortable (or not) when palpated.  These findings are subjective, but can help localize an area of injury or inflammation.

•Feelings or opinions are always subjective.

•Facts and observations that can be measured, weighed, or counted, are objective.

Incorrect options:

•Objective findings include: Measurement of blood pressure, assessment of the skin, or other findings that can be observed. 

•If the nurse documented that the patient did not appear to be in any pain or distress, or demonstrated no abdominal guarding during abdominal palpation, those would be objective findings.

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