A nurse is reinforcing teaching with a client who has been newly diagnosed with diabetes mellitus. Which of the following information demonstrates health literacy by the client?

Choice A reason: This statement is correct because the nurse should use objective terminology when documenting the occurrence. Objective terminology means using factual, unbiased, and verifiable information, such as the date, time, location, witnesses, and events of the occurrence. The nurse should avoid using subjective, opinionated, or judgmental language, such as blaming, criticizing, or speculating about the occurrence.
Choice B reason: This statement is incorrect because the nurse should not wait at least 12 hours to report the occurrence. The nurse should report the occurrence as soon as possible, preferably within an hour of the incident. The nurse should also notify the appropriate personnel, such as the charge nurse, the provider, and the risk manager. Delaying the report may compromise the client's safety and wellbeing, and the accuracy and completeness of the documentation.
Choice C reason: This statement is incorrect because the nurse should not omit the name of the individuals involved in the occurrence. The nurse should include the name of the client, the staff, and any other relevant parties, such as family members or visitors. The nurse should also document the role and actions of each individual, and their response to the occurrence. Omitting the name of the individuals may affect the accountability and follow-up of the occurrence.
Choice D reason: This statement is incorrect because the nurse should not document completion of the report in the client’s medical record. The nurse should document the occurrence report separately from the client’s medical record, and follow the facility's policy and procedure for filing and storing the report. The nurse should also document the occurrence in the client’s medical record, but only the facts and the nursing actions, not the details or the existence of the report. Documenting completion of the report in the client’s medical record may expose the facility to legal liability or litigation.

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.