Page 21 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

care is by using the patient’s own words wherever possible in the

documentation. If a patient describes her pain as feeling as if

someone stuck an icepick in her stomach, document that in the
narrative portion of the EHR in quotation marks as patient

described pain as, “feeling as if someone stuck an icepick in

stomach.” Also document the objective measurements, tests and

other reports that led you to your conclusions.

Examples include the following:

 Imprecise: Patient remains stable.

 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:

 See: Color, abnormality, posture.

 Smell: Breath, drainage, excretions.

 Hear: Sounds of breathing, crepitation, bowel sounds.

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

 Examples:

 “The wound feels indurated and measures 1.2cm in

diameter. Musty odor emanating from the wound.”

 “The patient appears jaundiced. Yellowish skin and

sclerae.”

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