護理師在電子病歷記錄時，哪項紀錄是可以接受的？
A nurse is documenting in a client's electronic health record. Which entry is acceptable?
- APhysician is incompetent醫師無能
- BClient states, 'I feel pain in my abdomen, 5/10 on the scale'✓ 正解病人表示：「我感到腹部疼痛，疼痛指數為 5/10」
- CThe nurse is unsure if the medication was administered護理師不確定藥物是否已給藥
- DClient appears happy today病人今天看起來很快樂
護理紀錄應遵循「客觀（Objective）」與「具體（Specific）」原則。護理記錄的目的是作為法律文件，必須如實反映病人的生理狀態與護理行為。主觀評價（如「快樂」）若無具體觀察支持，屬於主觀臆測，容易產生歧義。正確的紀錄應包含病人的直接陳述（引用語）以及可量化的評估結果，以提供精確的臨床數據。
Nursing documentation must follow the principles of being objective and specific. Because nursing records function as legal documents, they must accurately reflect the client's physiological status and nursing actions. Subjective evaluations such as 'happy' that lack concrete observational support are speculative and prone to ambiguity. Proper documentation should include the client's direct quoted statements together with quantifiable assessment findings to provide accurate clinical data.
在美國臨床環境中，法律訴訟風險極高，病歷紀錄（Documentation）被視為「若沒寫就等於沒做」。因此，美國護理師對於病歷紀錄的「客觀性」要求極度嚴格，絕不允許出現情緒性字眼或對他人的專業批評。