When gathering information relative to a complete health assessment, the nurse should include which in the decision-making process? (Select all that apply.)

A) Treat the health assessment as a legal document.
B) Use line drawings to explain and record pertinent findings.
C) Do not document findings on the computer while the patient is present.
D) Gather needed equipment before the start of the health assessment.
E) Write down "word for word" what the patient says as evidence of reliable documentation.

A prudent nurse gathers all needed equipment before the start of a complete health assessment. Simple line drawings can be used as illustrations of findings as well as teaching purposes during the health assessment interaction. Data from the history and physical examination should be recorded as soon as possible as memory fades as the day progresses. Documenting as you move through the examination works well for many examiners, but you just need to make you do not ignore the patient as you focus on the computer. The health assessment record is considered to be a legal document, and a prudent nurse proceeds cautiously to ensure its integrity is maintained. Although it is important to be accurate, it is virtually impossible to write down "word for word" everything that the patient may say during the assessment.