In documenting a postmastectomy patient, which sentence demonstrates objective documentation of behavior?

In documenting a postmastectomy patient, which sentence demonstrates objective documentation of behavior?

• A. "Ms. Scharfe shows manifestations of depression."
• B. "Ms. Scharfe is upset due to her mastectomy."
• C. "Ms. Scharfe is crying, refuses food, will not talk to her husband."
• D. "Ms. Scharfe experienced an emotional postop day, with periods of weeping and anorexia due to pain and anaesthetic, and was ignoring her husband."

Answer: (C)

The key idea is documenting observable, verifiable behavior rather than making interpretations or assigning causes. The sentence that lists crying, refusing food, and not talking to her husband records concrete actions you can see or confirm. It avoids labeling her mood or explaining why she’s acting this way, which makes it objective documentation. The other options either label her emotional state, imply a diagnosis, or attribute a cause to her behavior, which are subjective judgments or inferences and not as reliable for charting.

The key idea is documenting observable, verifiable behavior rather than making interpretations or assigning causes. The sentence that lists crying, refusing food, and not talking to her husband records concrete actions you can see or confirm. It avoids labeling her mood or explaining why she’s acting this way, which makes it objective documentation.

The other options either label her emotional state, imply a diagnosis, or attribute a cause to her behavior, which are subjective judgments or inferences and not as reliable for charting.