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Which is the correct way to document a patient's statement about symptoms experienced?

a) Use medical jargon for accuracy
b) Include personal opinions in the documentation
c) Quote the patient's exact words and note the time and date
d) Summarize the statement to save space in the chart

1 Answer

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Final answer:

The correct method for documenting patient statements is to precisely quote what the patient said about their symptoms, and record the time and date.

Step-by-step explanation:

The correct way to document a patient's statement about symptoms they have experienced is to quote the patient's exact words and note the time and date. This approach ensures the precision and reliability of the clinical record and provides an accurate account of the patient's experience, which is especially important since symptoms are subjective and not directly measurable. Medical professionals must avoid using medical jargon that the patient did not use or including personal opinions in the medical record. It is also not advisable to summarize the statement just to save space, as this can potentially omit critical information about the patient's condition.

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