Subjective vs. Objective Documentation

When you document your clinical records, you should be completely objective. Remember that patients have a right to obtain their records. If you have a ...

May 17, 2016

By:

EDIC

Stack of Medical Records

When you document your clinical records, you should be completely objective. Remember that patients have a right to obtain their records. If you have a particularly unpleasant patient and write, “Mrs. Smith was very nasty at her appointment and did not cooperate at all,” you can imagine her reaction if she read the note.

Don’t write your opinions about patients. If the patient says something unpleasant, document it as a quote rather than “judging” that she was unpleasant. If she reads the note, she will see what she said, not a judgmental comment from you.

You may have to “explain” what you meant by a subjective comment about a patient long after you wrote it. But you’ll never have to explain what a patient’s quote meant – it will be self-explanatory.