A nurse manager is teaching a newly licensed nurse about documenting information in a client's medical record. Which of the following entries by the newly licensed nurse indicates an understanding of the teaching?

Choice A reason: Documenting that a client is "uncooperative" is subjective and judgmental. Medical records should contain objective, factual information rather than personal opinions or interpretations. This entry does not meet professional standards of documentation. Choice B reason: Documenting the exact size and description of purulent drainage is objective, measurable, and factual. This entry provides clear clinical data that can be used for ongoing assessment and treatment planning. It avoids judgmental language and adheres to proper documentation standards. This makes it the correct answer. Choice C reason: Documenting a medication error from a previous shift is inappropriate because nurses should only document events that occurred during their own shift. Errors should be reported through incident reporting systems, not in the client’s medical record. Including this information in the chart is incorrect. Choice D reason: While documenting medication administration is appropriate, this entry is incomplete because it lacks essential details such as the route, time, and site of administration. Proper documentation requires comprehensive information to ensure continuity of care and safety.