How should Mrs. Bolton, a non-compliant and hostile patient, be documented in a medical record?

Study for the RHIT Domain 2 Health Data Maintenance and Analysis Test. Prepare with flashcards and multiple choice questions, each question offers hints and explanations. Get ready for your exam!

Documenting patient behavior in a medical record must adhere to professional standards and objectivity. The correct choice highlights the importance of clear, factual, and respectful language in medical documentation. Describing Mrs. Bolton as "noncompliant and hostile toward staff" accurately conveys her behavior without placing judgment or using derogatory terms. This terminology allows healthcare professionals to understand the patient's responses and interactions while maintaining a professional tone.

Using objective language is essential in medical records to ensure the information remains relevant and useful for future care and treatment decisions. It also helps to minimize bias, making it clear that the documentation is based on observed behavior rather than personal opinions. Objective documentation can be crucial in legal situations as well, protecting the healthcare provider by reflecting the true nature of the patient encounter. The other options do not meet these standards, as they carry subjective connotations and could be seen as unprofessional or disrespectful.

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