# Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the acute psychiatric ward. Nurses write their notes in focus charting, and the treatment team writes problem-oriented progress notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation). Restraint, when used, is recorded on a separate observation sheet. At 09:00 the client says, "I am the queen of this hospital, and I don't need your pills." Why should the nurse record these words in quotation marks rather than summarize them?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630052  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the acute psychiatric ward. Nurses write their notes in focus charting, and the treatment team writes problem-oriented progress notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation). Restraint, when used, is recorded on a separate observation sheet.

At 09:00 the client says, "I am the queen of this hospital, and I don't need your pills." Why should the nurse record these words in quotation marks rather than summarize them?

## 보기

1. It documents the nurse's assessment of her thinking
2. It meets the rule that every remark be charted in full
3. It records the statement as objective, verifiable data
4. It keeps her exact words free of the nurse's judgment **✔ 정답**

**정답: 4**

## 해설

Subjective data are recorded in the client's own words, in quotation marks, so the record shows exactly what was said without the nurse's paraphrase, label, or judgment. The nurse's interpretation belongs in the assessment, and observed behavior is still described separately as objective data.

## 심화 해설

Why quotation marks matter in nursing documentation

The client’s statement — “I am the queen of this hospital, and I don’t need your pills” — is subjective data: information that only the client can report about her own thoughts, feelings, or perceptions. In focus charting and SOAPIE notes, subjective data must be recorded verbatim, enclosed in quotation marks, because the goal is to preserve exactly what was said without the nurse’s interpretation creeping in.

When a nurse paraphrases, several risks arise. Paraphrasing inevitably selects which words to keep, which to drop, and which to replace with clinical shorthand. For example, writing “client expressed grandiose delusions about her authority and refused medication” is a reasonable clinical summary — but it is already an interpretation. The phrase “grandiose delusions” is a diagnostic label that reflects the nurse’s judgment about the content of her thinking. It does not tell the next reader precisely what the client said, how she phrased it, or what language she used. Quotation marks solve this by making the record a neutral container for the client’s own words.

The correct answer is 4: recording the statement in quotation marks keeps her exact words free of the nurse’s judgment. This does not mean the nurse has no clinical opinion — the nurse’s assessment belongs in a separate section of the note. In SOAPIE format, the Subjective component captures the client’s words; the Assessment component is where the nurse analyzes those words, identifies thought-content disturbances, and links them to the manic episode. Keeping these two layers separate protects both the client and the record.

Why option 1 is incorrect: quotation marks document what was said, not what the nurse thinks about it. The nurse’s assessment is a distinct documentation task. Why option 2 is incorrect: there is no rule that every remark must be charted in full. Nurses selectively document clinically relevant statements. Why option 3 is incorrect: a client’s reported words are subjective data by definition, not objective data. Objective data are observable and measurable — vital signs, observed behavior, physical findings. A direct quote is still the client’s self-report, even when recorded verbatim.

Key point! Verbatim quotation does not make subjective data objective. It makes subjective data accurate. The distinction between subjective and objective rests on the source of the information — the client’s report versus the nurse’s observation — not on whether the words are quoted or paraphrased.

This documentation principle has direct clinical consequences. In the acute psychiatric setting, a client’s exact words can later become evidence for treatment decisions, legal review, or evaluation of capacity. If the nurse writes “client claims to be the queen of this hospital,” the word “claims” already casts doubt on the client’s credibility. If the nurse writes “client states, ‘I am the queen of this hospital,’” the record simply reports what was said. The difference is subtle but meaningful.

The evidence base reinforces this concern. Research on clinical documentation shows that how clinicians write about patients can introduce stigma, even when the clinician intends only to summarize. Vick and colleagues examined notes documenting discharges against medical advice and found that word choices — such as “claimed,” “refused,” or “denied” — carried evaluative weight that shaped how subsequent readers perceived the patient . Their qualitative analysis highlighted that documentation is not a neutral transcript; it is a narrative constructed through language choices. When a nurse paraphrases a manic client’s grandiose statement as “delusional” or “nonadherent,” the note begins to function as a character judgment rather than a clinical observation.

This does not mean nurses should avoid clinical language entirely. It means clinical language belongs in the assessment, where it is explicitly framed as the nurse’s professional interpretation. The subjective section should remain as close to the client’s own voice as possible. Quotation marks are the mechanism that signals to every future reader: these are the client’s words, not the nurse’s summary of them.

| Documentation layer | What it contains | Example for this client |
| --- | --- | --- |
| Subjective | Client’s exact words in quotation marks | “I am the queen of this hospital, and I don’t need your pills.” |
| Objective | Observable behavior, measurable data | Pacing in hallway, loud speech, refused oral medication tray at 09:00 |
| Assessment | Nurse’s clinical interpretation | Grandiose delusion consistent with manic episode; impaired insight into need for treatment |

Watch out! A common exam trap is to assume that “objective” means “accurate” or “unbiased.” In nursing documentation, objective specifically means data obtained through the nurse’s senses or instruments. A direct quote is accurate, but it remains subjective because its source is the client’s report. The quotation marks protect accuracy; they do not change the data category.

The restraint observation sheet mentioned in the scenario follows the same logic. Restraint use is documented as objective data — time applied, type of restraint, circulation checks, behavior observed — because those are observable events. The client’s statements during restraint, however, would still be recorded as subjective data in quotation marks on the appropriate form. The documentation system separates what the client said from what the nurse observed precisely so that neither contaminates the other .

## 임상 시나리오

Recording Subjective Data VerbatimWhy quotation marks protect the client's voice in the chart
When a client makes a statement about their thoughts or feelings, record it as subjective data in their exact words enclosed in quotation marks. This keeps the entry free of the nurse's paraphrase, label, or judgment.

The nurse's clinical interpretation—such as labeling content as grandiose delusions—belongs in the Assessment section, not in the Subjective section. Observed behavior is documented separately as objective data.

CautionDo not paraphrase or substitute clinical shorthand for the client's words. Paraphrasing introduces the nurse's judgment and loses the precise language the client used, which may be critical for ongoing evaluation and treatment decisions.

## 핵심 개념

- **Subjective Data** — Information reported by the client about their own thoughts, feelings, or perceptions, recorded in the client's own words.
- **Objective Data** — Observable, measurable, and verifiable information gathered through assessment, such as vital signs or observed behavior.
- **SOAPIE** — Problem-oriented documentation format: Subjective, Objective, Assessment, Plan, Intervention, Evaluation.
- **Focus Charting** — Documentation method organized around a client concern or focus, using data, action, and response (DAR) categories.
- **Verbatim** — Word-for-word recording of a statement, enclosed in quotation marks, without paraphrasing or interpretation.

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