Page 22 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

• Accurate: All vitals are normal. Bowel and bladder have

returned to full function. Ate full diet.

• Subjective: Appears drunk.

• Objective: Slurred speech. Smells of alcohol.

• General: Wound OK.

• Specific: Surgical incision healing. No sign of infection.

Rely on your senses to describe your observations:

• Sight: Color, abnormality, posture.

» “The patient appears jaundiced. Yellowish skin and

sclerae.”

• Smell: Breath, drainage, secretions.

» “There was a smell of melena when I entered the

room.”

» “Musty odor emanating from the wound.”

• Hear: Sounds of breathing, crepitance, bowel sounds.

» “Crackles were heard upon auscultation of the lower

lungs.”

• Feel: Hot or cool, dry or moist, soft or firm.

» “Skin is hot to touch.”

» “The wound feels indurated and measures 1.2cm in
diameter.”

Refrain from documenting derogatory, discriminatory, or other

callous comments that could be viewed as disrespectful
or prejudicial by a jury such as “stubborn”, “crock”, “loser”,

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