Which examples of documentation would be most informative to transcribe to the patient's medical record?
A) "Patient consumed two slices of bread and a cup of coffee at breakfast."
B) "Patient does not appear to be hungry after consuming breakfast."
C) "Patient ate a small amount of bread and drank a little coffee for breakfast."
D) "Patient ate well for breakfast, lunch, and dinner and seems content."

Question

Quizplus · Accepted Answer

Use of the words "appears to" or "seems" in phrases such as "appears to be resting" should be avoided. Document the behavior; the patient either is or is not resting. Words that have ambiguous meanings and slang should not be used in documentation. For example, how much is "a little," "a small amount," or a "large amount"? What do phrases such as "ate well" and "taking fluids poorly" mean? Although such words give a general idea of what is meant, they are not specific.

Which Examples of Documentation Would Be Most Informative to Transcribe