— 照護管理 · MEDIUM · MCQ —
護理師在評估新進人員的紀錄。下列哪項紀錄最適當且具法律效力？
A nurse is evaluating a new nurse’s documentation. Which entry is most appropriate and legally sound?
- APatient is lazy and refuses to participate in physical therapy.病人很懶惰且拒絕參與物理治療。
- BClient reports sharp abdominal pain rated as 7/10.✓ 正解客戶報告腹部劇痛，評分7/10。
- CClient seems to be depressed after speaking with the physician.與醫師交談後，客戶似乎心情低落。
- DAdministered medication, but it didn't seem to work well.已給予藥物，但似乎效果不佳。
— Explanation · 中文詳解 —
護理紀錄應客觀、具體且無偏見。選項 B 描述了病人主訴疼痛程度，具備客觀評估數據。其他選項均帶有主觀情緒用語（如 depressed, lazy, didn't work well），缺乏專業性與事實根據。
Nursing documentation should be objective, specific, and unbiased. Option B describes the patient's subjective complaint of pain with objective assessment data. The other options contain subjective, emotional language (such as "depressed," "lazy," "didn't work well") and lack a professional, fact-based foundation.
✦ 台美臨床差異
美國醫護紀錄極度強調「客觀描述」以規避法律風險；台灣紀錄相對較為簡略，但現今也朝向客觀化邁進。