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Subjective Data in Documentation​ Select the subjective words or phrases present in the plan of care documentation. Upon assessment of vital signs, the client’s blood pressure was 190/92. They were questioned about their medication adherence, and slowly during the course of the client interview, it was shared that they had not refilled or taken their hypertension medications in over one year. This client did not appear to understand the severity of their health issues at this time. They are a poor historian and seemed to have a lack of understanding of how quickly this event could have taken a much worse route. Client education and support for the current situation as well as a lengthy discussion about the consequences of non-adherence to medications was completed.
SCIENCE
HEALTH SCIENCE
NURSING

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