When charting assessment data, which practice should be avoided?

• A. Recording only explicit measurements
• B. Using standardized NANDA labels
• C. Using words like appears or seems
• D. Including etiologies

Answer: (C)

In charting assessment data, you want notes to reflect objective, observable information or the patient’s own statements. Saying that someone “appears” or “seems” anxious is a subjective impression that can vary from one clinician to another and isn’t reliably supported by data. The goal is to anchor the record in concrete facts or direct quotes, so the chart communicates exactly what was measured or reported. For example, document patient-reported anxiety and any measurable signs (such as a pulse of 102, restlessness, or agitation) rather than labeling the patient with an interpretation like “appears anxious.” This approach keeps the record precise, reproducible, and useful for others who review the chart later.

Other practices listed are generally appropriate in charting. Recording explicit measurements is essential because numbers provide clear, objective data. Using standardized NANDA labels helps maintain consistent terminology across charts. Including etiologies, while related to the diagnostic process, belongs more to the nursing diagnosis discussion than the assessment data itself, so it’s not part of the assessment notes.