Author Question: When documenting what a patient said in the medical record, use: a. past tense (e.g., She stated ... (Read 40 times)

vicky · **on:** Jun 27, 2018

When documenting what a patient said in the medical record, use:

a. past tense (e.g., She stated that she was hungry for days).
b. quotation marks (e.g., I was hungry for days).
c. a summary of your idea of what was being said (e.g., I believe the patient was hungry).
d. it is not necessary to document what the patients says.

Question 2

What should be avoided when documenting in a medical record?

a. Spelling out abbreviations
b. Using abbreviations
c. Using approved abbreviations
d. Using a 0 before a period in a report of measurement