Which of the following is FALSE about clinical documentation? Which of the following is FALSE about clinical documentation?

Which of the following is FALSE about clinical documentation? Which of the following is FALSE about clinical documentation? Patients and families often use vague terms like ‘lethargic’ – MOST notes only contain these vague terms in the chief complaint or in direct quotation in the HPI – and progress to include more descriptive and clearly understood language. The source of information should be recorded/included in the note. The medical record reads like a story that describes what is heard, seen and includes the medical decision-making. Listing differential diagnoses and reasons for diagnostic tests is necessary and more valuable to describe the clinician’s thought process than a lengthy history, physical exam or list of orders. All are TRUE about clinical documentation