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

a) Use medical jargon to ensure accuracy
b) Paraphrase the patient's statement using plain language
c) Omit the patient's statement if it is unclear
d) Record the statement exactly as spoken, including slang and colloquial language

User Dnatoli
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1 Answer

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Final answer:

The correct way to document a patient's statement about symptoms is to record the statement exactly as spoken by the patient, including any slang or colloquial language, to accurately capture their subjective experience.

Step-by-step explanation:

When documenting a patient's statement about symptoms experienced, it is important to record the statement exactly as spoken, including slang and colloquial language. This ensures that the patient's subjective experience is captured accurately. While medical professionals often use specific terms or jargon, in this case, it is essential to record the patient's own words to provide a clear and complete picture of the patient's experience to anyone reviewing the record. Enunciating clearly and using respectful language are also key, but they relate to how healthcare providers should communicate rather than how patients' statements should be documented.

Regarding the provided options: while option 'b' suggests paraphrasing using plain language, it is not as precise as option 'd' for capturing the patient's exact words. Option 'a', using medical jargon, is inappropriate because it may not reflect the patient's own descriptions, and option 'c', omitting the statement, would leave out potentially valuable information.

User Gregory Kalabin
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