When documenting client information, how should a nurse prepare a "factual" record?

Preparing a "factual" record in client documentation is crucial for ensuring clear, accurate, and objective communication about the patient's condition and care. A factual record is characterized by its basis in objective data, which can be observed or measured, rather than subjective interpretations or personal opinions.

Recording descriptive and objective information is essential because it creates a reliable account of the patient's health status, interventions performed, and responses to those interventions. This type of documentation reduces ambiguity and enhances the ability of other healthcare providers to understand the patient's situation without misinterpretation. For instance, instead of writing "the patient seems to be in pain," a factual record would document specific signs of distress such as “the patient grimaces when moving and rates pain as 8 on a scale of 0 to 10.”

Summarizing the patient's history offers context but may lack the specificity and clarity required for factual records. Including personal opinions introduces bias and may alter the perception of the patient's condition, which can lead to potential misunderstandings. Creating a narrative of the client's experience can be informative but is often more subjective and less structured, which may stray from the objective criteria needed for factual documentation. Therefore, the best practice is to focus on objective and measurable observations to maintain the integrity and professionalism of