Which of the following statements best follows documentation best practices in a surgical history?
A Patient says he feels fine.
B Patient denies fever, nausea, or weight loss.
C Patient is not sure about his symptoms.
D Patient thinks he might have an infection.
Solution
Correct Answer: Option B
The correct statement, "Patient denies fever, nausea, or weight loss," exemplifies documentation best practices because it uses clear, objective, and specific clinical terms that accurately reflect the patient's surgical history. This phrasing avoids vague or subjective expressions, ensuring precise communication critical for surgical decision-making. Additionally, documenting negative findings like denial of key symptoms helps guide diagnosis, risk assessment, and perioperative management. Accurate and detailed symptom documentation supports safe preoperative evaluation and postoperative care by providing actionable clinical information.
Reference: Sabiston Textbook of Surgery, Townsend, 21st Edition.