Final answer:
When documenting subjective data, a nurse should use the client's own words and place them in quotation marks to maintain accuracy and clarity, and to capture the patient's personal experience without interpretation or bias.
Step-by-step explanation:
When documenting subjective data, the nurse should primarily use the client's own words placed in quotation marks. This approach ensures that the patient's experiences and descriptions are reported with utmost accuracy, reflecting their personal perspective. The use of direct quotes allows the documentation to capture the patient's voice without interpretation or bias, which is crucial in healthcare settings.
Moreover, by using the client's own words, the nurse provides a reliable basis for medical decisions that may be made by other care providers who will read the record later. This practice enhances the quality of care by promoting a clear understanding of the patient's symptoms, feelings, concerns, or the description of the pain and its characteristics from the patient's viewpoint.
While paraphrasing and summarizing can also be part of documenting subjective data, the integrity of the patient's original language and sentiment should not be compromised. Validation with family members may provide supplementary knowledge, but it is not a substitute for recording the patient's own expressions. Using nonspecific words is discouraged as it can lead to a lack of clarity and precision in the healthcare records.