Contents Legal system Malpractice Avoiding malpractice Medical record Introduction Proper documentation Subjective vs objective Legal considerations Managing records Record storage Releasing records Viewing records Withholding records Selling records FAQs Patients' rights QUIZ

Subjective vs. objective entries Health care providers should only document factual and objective information from their own treatment and/or observation of the patient. When documenting information derived from other sources, for example, other health care providers, other medical records, or entries in the same medical record, be sure to reference the source of that information. Subjective documentation is far less clinically useful than objective information. Examples of objective/subjective charting include: Objective statements Subjective statements Half of breakfast eaten Diet taken fairly No complaints of pain Had a good day Surgical incision healing- no signs of infection Wound OK Thrashing in bed Appears restless IV site clear and infusing at 40 drops per minute IV running well A means by which health care providers can document factual and relevant information is by specifically charting information based upon what is: Seen - charting observations regarding bleeding, deformities, drainage, color of urine, patient posture and/or attitude; Heard - the patient's complaints/statements, moaning, breathing abnormalities, bowel sounds; Smelled - malodorous drainage, alcohol or acetone on breath, fecal or vomitus odor; Felt - areas of induration, hot, cold, dry or moist skin, motion at a fracture site. When a patient is discharged, it is good medical practice to write a final note commenting on the stability of the patient by noting the patient's vital signs, the status of recovery from the condition on admission, or for an elective admission, the status of recovery from the elective treatment/surgery. The note should completely document the discharge instructions given to the patient and/or the patient's family members. Following a patient's discharge, health care providers should promptly complete the medical record in accordance with hospital requirements to enable the medical record department to secure the patient record expeditiously and safely.