What does it means to document accurately and appropriately?

The medical interview serves several functions. It is used to collect information to assist in diagnosis of the present illness, to understand the patient’s values, to assess and communicate prognosis, to establish a therapeutic relationship and to reach agreement with the patient about further diagnostic procedures and therapeutic options. The interview also offers an opportunity to influence patient behaviors.  Discuss the following:  Please answer the following questions and include your rationale and evidence-based research to support your written work.

•What does it means to document accurately and appropriately?

•What are the documenting guidelines? When is it appropriate to use abbreviations?

•What is the difference between subjective and objective data?

•What does it mean to demonstrate clinical reasoning skills?

•How can you use clinical reasoning to plan the organization of a comprehensive exam?

•How will you document variations of normal and abnormal assessment findings?

•What factors influence appropriate tools and tests necessary for a comprehensive assessment?

•Reflect on personal strengths, limitations, beliefs, prejudices, and values.

•How will these impact your ability to collect a comprehensive health history?

•How can you develop strong communication skills.

•What interviewing techniques will you use to interview the patient to elicit subjective health information about their health history?

•What relevant follow-up questions will you use to evaluate patient condition?

•How will you demonstrate empathy for patient perspectives, feelings, and sociocultural background?

•What opportunities will you take to educate the patient?

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