In nursing assessment, which should be charted?

• A. Inferences
• B. Both cues and inferences
• C. None of the above
• D. Cues

Answer: (D)

In nursing assessment, you chart observable data and patient-reported information—these are cues. Cues include vital signs, physical findings, lab results, and what the patient says about how they feel. Inferences are the nurse’s interpretations or conclusions drawn from those data, and they shouldn’t be recorded as if they are exact facts. They belong in the analysis stage or in the nursing diagnoses and care plan, supported by the cues you collected. By documenting only cues, you keep the record objective, verifiable, and legally sound. For example, note “pt reports abdominal pain of 6/10” or “pt appears anxious and is fidgeting” as cues; reserve statements like “the patient is depressed” for a formal diagnosis supported by multiple cues and appropriate assessments.