Correct Documentation: Objective Wording

Health Assessment & Documentation · Question from the ATI PN Fundamentals 2023 Proctored Exam study set

Correct answer: "The client is diaphoretic."

Why this is the answer

This is an objective, factual, measurable observation free of vague language, judgment, or bias, meeting professional documentation standards.

The bigger concept

Charting should record what you observed, measured, or heard the client say — not your interpretation. 'Client is diaphoretic' is observable; 'client seems anxious' or 'client is uncooperative' are judgments. Use quotation marks for the client's own words, chart in real time with date and time, never leave blank lines, and correct errors with a single line, initials, and date. Documentation is a legal record, so vague or biased entries are the classic wrong answers.

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