Chart notes need to be

• A. Technical and objective
• B. Nonjudgmental
• C. Opinionated
• D. Casual

Answer: (B)

Chart notes should be nonjudgmental, neutral, and factual. When documenting a patient encounter, the emphasis is on what was observed, what the patient reports, and what actions were taken, not on personal opinions or judgments about the patient. Using nonjudgmental language keeps the record accurate and usable for any clinician who reads it, supports clear communication, and helps protect patient rights and legal defensibility.

For example, note that the patient reports difficulty adhering to a plan, or that a medication was refused, rather than labeling the patient with a moral or character judgment. It’s fine to be precise and objective, but the goal is to describe situations and behaviors in neutral terms so the chart remains professional and trustworthy. Casual or opinionated wording disrupts clarity and can lead to misinterpretation, while nonjudgmental, objective phrasing preserves the integrity of the record.