Charting Systems and Patient Records · CDA

Which of the following should NOT be included in clinical chart entries?

  1. Objective findings and treatment provided
  2. Prognosis and follow-up recommendations
  3. Subjective opinions about patient’s personality
  4. Dates and provider initials
Show answer and explanation

Correct answer: Subjective opinions about patient’s personality

Charts should be professional and factual. Personal opinions or derogatory remarks are inappropriate and could undermine trust or expose the practice to liability.

Difficulty: Medium Question 17 of 20

Practice all 20 Charting Systems and Patient Records questions

Keep practicing

More Charting Systems and Patient Records questions