What is a best practice for documenting subjective data?

Using direct quotes from clients to maintain accuracy is considered a best practice for documenting subjective data because it captures the client's exact words and feelings without alteration. This approach helps ensure that the documentation reflects the client's thoughts and emotions as they intended, which is crucial in providing personalized and accurate care. By quoting clients directly, Personal Support Workers can convey the nuances of their emotional states, which may be lost through paraphrasing or summarization.

This practice also enhances the credibility and integrity of the documentation, making it a reliable source of information that can be referenced in future care planning or when communicating with other team members. Furthermore, it respects the client’s voice, reinforcing their autonomy and the therapeutic relationship.

In contrast, summarizing a client's feelings may overlook important aspects of their experience, interpreting statements can introduce bias or misunderstanding, and documenting personal opinions can skew the objectivity necessary in professional documentation.