Identifying Documentation Errors

Patient is lazy and refuses to participate in therapy.

• Subjective or judgmental language

• Vague descriptions that lack measurable data

• Unclear cause-and-effect assumptions

• Lack of professional tone

• Missing specific details

Answer explanation

"Lazy" is a judgment, not an objective observation.

Mr. Dela Cruz had a great session today!

• Subjective or judgmental language

• Vague descriptions that lack measurable data

• Unclear cause-and-effect assumptions

• Lack of professional tone

• Missing specific details

Answer explanation

"Great session" is unclear; needs measurable details.

Patient’s strength is better than before.

• Subjective or judgmental language

• Vague descriptions that lack measurable data

• Unclear cause-and-effect assumptions

• Lack of professional tone

• Missing specific details

Answer explanation

"Better" is subjective; specify improvements with data.

The patient was upset and didn’t cooperate.

• Subjective or judgmental language

• Vague descriptions that lack measurable data

• Unclear cause-and-effect assumptions

• Lack of professional tone

• Missing specific details

Answer explanation

"Upset" is an interpretation; describe behaviors instead.

Therapist assisted the patient in doing exercises.

• Subjective or judgmental language

• Vague descriptions that lack measurable data

• Unclear cause-and-effect assumptions

• Lack of professional tone

• Missing specific details

Answer explanation

What exercises? What kind of assistance? Needs specifics.

Patient completed sit-to-stand exercises well.

• Subjective or judgmental language

• Vague descriptions that lack measurable data

• Unclear cause-and-effect assumptions

• Lack of professional tone

• Missing specific details

Answer explanation

"Well" is unclear; specify repetitions, time, or quality.

The patient’s left hand is getting stronger each session.

• Subjective or judgmental language

• Vague descriptions that lack measurable data

• Unclear cause-and-effect assumptions

• Lack of professional tone

• Missing specific details

Answer explanation

"Stronger" needs quantifiable data like grip strength.

Patient can now dress himself better.

• Subjective or judgmental language

• Vague descriptions that lack measurable data

• Unclear cause-and-effect assumptions

• Lack of professional tone

• Missing specific details

Answer explanation

"Better" lacks measurable comparison (e.g., time, assistance).

Therapy went smoothly, and the patient tolerated it well.

• Subjective or judgmental language

• Vague descriptions that lack measurable data

• Unclear cause-and-effect assumptions

• Lack of professional tone

• Missing specific details

Answer explanation

"Smoothly" and "tolerated well" are unclear; use specifics.

Patient was in pain but pushed through anyway.

• Subjective or judgmental language

• Vague descriptions that lack measurable data

• Unclear cause-and-effect assumptions

• Lack of professional tone

• Missing specific details

Answer explanation

"Pushed through" is subjective; document pain scale, actions.