Question

You should ____ write something negative about the client in the medical record.

a) Always
b) Never
c) Occasionally
d) Sometimes

Answer 1

In medical record documentation, one should never include negative or judgmental comments about a client. Medical records are objective documents that should only contain factual information based on observable behaviors and symptoms.

Step-by-step explanation:

The question involves proper documentation practices in medical records. You should never write something negative about the client in the medical record. Medical records are legal documents that must be factual, objective, and free of any subjective or judgmental language that could be interpreted as unprofessional or defamatory. Negative comments about a patient's character or assumptions about their motives are unprofessional and could have legal consequences. Instead, healthcare professionals should focus on describing behaviors, symptoms, and facts without attaching personal judgement or negative labels.