When discovering subjective data, recognize that they relate to:

A. The LPN should document the care that he/she provided and the care that was given by unlicensed assistive staff.: While the LPN is responsible for documenting their own care, they are not responsible for documenting care provided by unlicensed assistive personnel (UAP). Each staff member is responsible for documenting their own care.

B. The registered nurse must document all care provided by the nursing assistants because the RN is responsible for all patient care.: While RNs oversee patient care, UAPs and LPNs must document the care they perform themselves.

C. All staff members should document all of the care that they have provided.: Every healthcare provider is responsible for documenting their own interventions to maintain accurate and legal records.

D. All staff should document all care they provided, but the RN (as the only independent practitioner) must sign their notes.: While RNs may sign their own documentation, they do not need to sign documentation made by LPNs or UAPs unless verification is required.

A. Interview and physical examination: The two primary methods of data collection in nursing are:

• Interview (subjective data: patient history, symptoms, concerns)

• Physical examination (objective data: vital signs, assessment findings)

B. Review of the doctor's orders and the Kardex: This provides supplementary data but does not directly collect patient information.

C. Written report by patient and family: This may provide valuable subjective data but is not a primary method of data collection.

D. Review of the chart and the nurse’s notes: This is reviewing existing documentation, not actively collecting data.