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

Stack of Medical Records

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.

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