A nurse documents the client’s vital signs and symptoms in the electronic health record before deciding on possible causes. Which phase of the nursing process is the nurse completing?

Choice A reason: Implementation involves performing nursing interventions to achieve outcomes, not recording observations. Documenting alone does not constitute intervention. Choice B reason: Assessment is the systematic collection of data, including vital signs, symptoms, and observations, to understand the client’s current status. Recording this data in the electronic health record reflects the assessment phase of the nursing process. Choice C reason: Planning involves setting goals and determining interventions after assessment. The nurse has not yet analyzed the data to plan care. Choice D reason: Evaluation involves determining the effectiveness of interventions based on client responses. At this stage, no interventions have been implemented, so evaluation is not occurring.