Charting Systems and Patient Records · CDA

Which of the following is considered poor practice when documenting patient records?

  1. Writing clear, factual, and fully objective clinical entries
  2. Recording subjective or derogatory remarks about patients
  3. Signing and dating each individual entry made in the record
  4. Updating the medical history at every scheduled patient visit
Show answer and explanation

Correct answer: Recording subjective or derogatory remarks about patients

Subjective, judgmental or derogatory comments are unprofessional and may harm patient trust; records should remain objective and factual.

Difficulty: Medium Question 5 of 20

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