What is an acceptable statement to document about a patient's behavior or condition?

Appropriate Documentation in Patient Records

Option C, "The patient urinated in the water pitcher," is the only acceptable statement to document about a patient because it objectively describes an observable behavior without subjective judgment or stigmatizing language. 1, 2

Principles of Proper Medical Documentation

Medical documentation should prioritize factual, observable data while avoiding subjective judgments or stigmatizing language. The American College of Physicians emphasizes that clinical documentation should be brief, thoughtful, and efficiently convey findings and actions taken 1.

Analyzing Each Option:

1. Option A: "Patient presents to ER and is being obnoxious"

   • This contains subjective judgment ("obnoxious")
   • Uses stigmatizing language that could harm the patient-clinician relationship
   • Fails to describe specific observable behaviors 1, 2

2. Option B: "The patient smells bad and has probably not had a shower in a week"

   • Contains subjective assessment ("smells bad")
   • Includes speculation without evidence ("probably not had a shower in a week")
   • Uses potentially stigmatizing language 1, 2

3. Option C: "The patient urinated in the water pitcher"

   • Documents a specific, observable behavior
   • Uses factual, objective language
   • Provides clinically relevant information about the patient's behavior
   • Avoids subjective judgment 1, 2

4. Option D: "The patient is drunk"

   • Makes a diagnostic claim without supporting evidence
   • Uses potentially stigmatizing language
   • Better alternatives would be to document objective findings like "patient exhibits slurred speech, unsteady gait, and smells of alcohol" 1, 2

Best Practices for Patient Documentation

When documenting patient behaviors:

• Document factual, observable data including vital signs, physical examination findings, and objective behaviors 2
• Use quantitative measurements whenever possible 2
• Avoid stigmatizing language that could harm the patient-clinician relationship 1
• Maintain clarity and organization in medical documentation 1
• Use clear, specific descriptions rather than vague or judgmental terms 1

Common Pitfalls to Avoid

• Using subjective language in the objective section of notes 2
• Including personal judgments about the patient's character or appearance 1
• Making diagnostic claims without supporting evidence 1
• Using language that could be perceived as disrespectful or stigmatizing 1

Documentation Recommendations

When documenting concerning patient behaviors:

1. Focus on specific, observable actions
2. Use neutral, non-judgmental language
3. Include relevant context when appropriate
4. Document factual information that may be clinically relevant
5. Avoid assumptions about the patient's intentions or character

By following these principles, healthcare providers can maintain professional documentation that respects patient dignity while accurately capturing clinically relevant information.