What does the 'C' in "C's in Charting - Client's Words" refer to?

The 'C' in "C's in Charting - Client's Words" specifically refers to the patient's own phrasing. This concept emphasizes the importance of documenting the words that a patient uses when they describe their symptoms, feelings, or concerns. Using the patient's own words in charting helps ensure that the healthcare team accurately captures the patient's perspective and experiences, which can be crucial for diagnosis, treatment planning, and building rapport.

This approach also enhances the clarity and authenticity of the medical record, as it reflects the patient's voice and may reveal insights that clinical language could obscure. For example, if a patient states, "I feel like I can't breathe," documenting this verbatim can carry different implications than a simplified interpretation of the same sentiment. Using the patient's language can improve communication among healthcare providers and ensure that care is more aligned with the patient's actual experiences and concerns.