Question

When writing clinical notes you should only write what?

Answer 1

1. Be concise. ...
2. Include adequate details. ...
3. Be careful when describing treatment of a patient who is suicidal at presentation. ...
4. Remember that other clinicians will view the chart to make decisions about your patient's care. ...
5. Write legibly. ...
6. Respect patient privacy.

Answer 2

Only factual information should be written in clinical notes.

Explanation:

• Information that only deals with facts are referred to as factual information. It is brief, non-explanatory, and rarely provides extensive background information on a subject.
• Truthful or focused with exact details or info instead of thoughts or emotions about it, factual is defined as real or concerned with specific facts or data.
• A declaration that it is 20 ° c today is an example of something which is true.
• Temperature data from the last 5 years is an example of factual data.