A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (ISBARR) on a client. Which of the following information should be included in the situation component?

Choice A reason: SOAP documentation is not the correct method for documenting only unexpected findings. SOAP documentation requires the nurse to document both normal and abnormal findings, as well as the plan of care for the client.

Choice B reason: Problem oriented medical record (POMR) is not the correct method for documenting only unexpected findings. POMR is a method that organizes the documentation around the client's problems, rather than the source of data. It consists of four components: database, problem list, plan, and progress notes.

Choice C reason: Focus charting (DAR) is not the correct method for documenting only unexpected findings. Focus charting is a method that uses the nursing process and the client's perspective to document the client's care. It consists of three components: data, action, and response.

Choice D reason: Charting by exception (CBE) is the correct method for documenting only unexpected findings. CBE is a method that assumes that all standards of care are met unless otherwise documented. It allows the nurse to document only significant or abnormal findings, such as changes in the client's condition, interventions, or outcomes.

Choice A reason: Use of restraints is not included in the outcome category, but in the process category. The process category measures the nursing interventions and activities that affect the client's health outcomes. Use of restraints is a nursing intervention that can have negative effects on the client's physical and psychological wellbeing, such as injuries, infections, agitation, and depression.
Choice B reason: Client admissions is not included in the outcome category, but in the structure category. The structure category measures the characteristics and resources of the health care setting that affect the quality of care. Client admissions is a characteristic that reflects the volume and complexity of the client population and the demand for nursing services.
Choice C reason: Hospital readmissions is included in the outcome category. The outcome category measures the results and consequences of the nursing care provided to the clients. Hospital readmissions is a result that indicates the effectiveness and continuity of the nursing care. A high rate of hospital readmissions can suggest poor quality of care, inadequate discharge planning, or lack of follow-up care.
Choice D reason: Staffing is not included in the outcome category, but in the structure category. The structure category measures the characteristics and resources of the health care setting that affect the quality of care. Staffing is a resource that reflects the quantity and quality of the nursing staff, such as the number, education, experience, and skill mix of the nurses.