No matter the Allied Health profession in which you are practicing, from social work to physical therapy, documentation should be objective, not subjective. It should not be judgmental, but should be an accurate, descriptive representation of what you observed and heard. Keep in mind the types of documentation may vary depending upon the area of Allied Health profession in which you are practicing, but below are a few examples to illustrate objective versus subjective documentation.
- “Patient was observed with glassy eyes, stumbled and staggered as he entered the office. Patient had a strong odor of alcohol on his breath.”
- "Patient is non-compliant with treatment"
With each missed appointment or non-compliance, examples of documentation may include:
- “Patient no-showed for his scheduled appointment.”
- “Patient indicated she is taking medication 3 times per week and not daily as prescribed.”
- “Patient’s treatment plan reflects exercises 3 times per day at 10-minute increments. Patient indicated he has been performing his exercises 1 time per day at 5-minute increments and is reportedly limited by pain and discomfort.”
- "Patient was hostile and angry."
- "Patient had a loud tone of voice and stated, I hate coming to see you, and I’m not coming back anymore if you are going to ask me those questions."
It is important that your documentation is objective and non-judgmental. Documentation should reflect the care provided. Be sure to check your profession’s ethical guidelines on documentation principles. When you have questions, it is best to consult an attorney for guidance.
Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM
Healthcare Practice and Risk Management Innovation Officer
Trust Risk Management Services, Inc.
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