# Situation: The occupational health nurse of a furniture factory with 300 workers on day and night shifts is asked to start a health education program on noise and hearing protection. The night-shift session on earplug use ran from 10:00 to 10:40 p.m. and ended with a return demonstration of earplug fitting. Which entry in the health education record is written CORRECTLY?

> source: MyMerci (mymerci.kr)  
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> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: The occupational health nurse of a furniture factory with 300 workers on day and night shifts is asked to start a health education program on noise and hearing protection.

The night-shift session on earplug use ran from 10:00 to 10:40 p.m. and ended with a return demonstration of earplug fitting. Which entry in the health education record is written CORRECTLY?

## 보기

1. 10:50 p.m. Demonstrated earplug fitting to 30 workers; 27 fitted them correctly on return demonstration. **✔ 정답**
2. 10:50 p.m. Taught 30 workers earplug fitting by demonstration; return demonstration was done.
3. 10:50 p.m. Taught 30 workers how to fit earplugs; the workers seemed to understand the steps well.
4. 9:30 p.m. Earplug fitting taught to 30 workers; 27 of 30 fitted them correctly on return demonstration.

**정답: 1**

## 해설

A teaching record must be timely, objective, and complete: it is written after the teaching and states the topic, participants, method, and the measured result of the evaluation. The 10:50 p.m. entry with 27 of 30 correct return demonstrations meets all of these. Charting before the session, subjective wording such as "seemed to understand," and an entry that omits the evaluation result each break a documentation principle.

## 심화 해설

Documentation of a Teaching Session

The correct entry is the one that is written after the session ends, states the measurable outcome, and avoids subjective language. A health education record follows the same principles as clinical documentation: it must be timely, objective, and complete.

The session ran from 10:00 to 10:40 p.m., so the entry must be timed at or after 10:40 p.m. The 10:50 p.m. time in options 1, 2, and 3 is therefore acceptable, while option 4 is timed 9:30 p.m.—before the session even occurred. Charting ahead of time is a serious documentation error because it records an event that has not yet happened and can create a false record if the session is cancelled or changed.

The second key element is objectivity. Option 3 states that workers “seemed to understand the steps well.” The word “seemed” is a subjective impression, not a measurable fact. Documentation must describe what was observed or measured, not what the nurse inferred about the learners’ internal state. This principle is emphasized in nursing documentation research: records should capture observable, verifiable data rather than evaluative opinions [3].

The third requirement is completeness, specifically the inclusion of the evaluation result. Option 2 records that a return demonstration was done, but it does not state how many workers performed correctly. Without a measured outcome, the reader cannot determine whether the teaching was effective. Option 1 provides the full picture: 30 workers participated, and 27 fitted earplugs correctly on return demonstration. This is a quantifiable, objective outcome that allows the nurse and other team members to identify who needs further instruction.

| Documentation element | Option 1 | Option 2 | Option 3 | Option 4 |
| --- | --- | --- | --- | --- |
| Timed after session (after 10:40 p.m.) | Yes (10:50 p.m.) | Yes (10:50 p.m.) | Yes (10:50 p.m.) | No (9:30 p.m., before session) |
| Objective wording | Yes | Yes | No (“seemed to understand”) | Yes |
| Measured evaluation result | Yes (27 of 30 correct) | No (result not stated) | No | Yes (27 of 30 correct) |
| Complete and accurate | Yes | No | No | No (wrong time) |

Watch out! “Return demonstration was done” is not the same as “27 of 30 fitted them correctly.” The first tells you an activity occurred; the second tells you whether the teaching worked. Documentation must include the result of the evaluation, not just that an evaluation took place.

Key point! Subjective phrases such as “seemed to understand,” “appeared comfortable,” or “tolerated well” are not acceptable in nursing records. Replace them with observable behaviors or measurable data. In a teaching record, the measurable data is the number or percentage of learners who demonstrated the skill correctly.

The documentation literature supports this approach. Reviews of nursing documentation consistently identify timeliness, accuracy, and completeness as core quality criteria [3]. Structured educational interventions, such as reflective models, have been shown to improve documentation quality precisely because they train nurses to record specific, observable details rather than vague impressions . The same logic applies to health education records: a well-written entry allows any reader to know exactly what was taught, to whom, when, and with what measurable outcome.References (research sources)

- [3]Evaluating nursing documentation - research designs and methods: systematic review.Meta-analysis/systematic reviewSaranto K, Kinnunen UM (2009) · DOI: 10.1111/j.1365-2648.2008.04914.x

## 임상 시나리오

Teaching Documentation EssentialsTimely, objective, and outcome-based recording
A teaching record must be written after the session ends and include the topic, participants, method, and measured evaluation result. For a session ending at 10:40 p.m., an entry at 10:50 p.m. is acceptable.

The best entry states a quantifiable outcome: 27 of 30 workers fitted earplugs correctly on return demonstration. This allows the reader to judge teaching effectiveness objectively.

CautionAvoid subjective wording such as "seemed to understand" and never chart before the session occurs. Omitting the evaluation result makes the record incomplete.

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## 핵심 개념

- **Return demonstration** — A teaching evaluation method where learners perform a skill to confirm they can do it correctly.
- **Objective documentation** — Recording only observable, measurable facts rather than personal interpretations or feelings.
- **Timely documentation** — Charting an event at or after the time it actually occurred, never before.
- **Measurable outcome** — A specific, quantifiable result such as 27 of 30 workers performing correctly.

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