What is the best way to record in a patient's report that he only slept from about 1:00 a.m. to 4:30 a.m.?
a. Patient reports difficulty sleeping.
b. Patient is sleeping poorly.
c. Patient states, "I only slept 3 1/2 hours last night.".
d. Patient needs help sleeping.
c
FEEDBACK: a. Incorrect. This is not specific.
b. Incorrect. This is not specific.
c. Correct. The best way is to use a direct quote and place the entry in quotation marks.
d. Incorrect. This is a conclusion, not a specific reference to what the patient said.
Health Professions