When using subjective documentation, what should always be indicated?

When using subjective documentation, it is vital to indicate that it is a personal interpretation. This means that the information recorded reflects the individual’s thoughts, feelings, or observations, rather than an objective fact that can be verified. Subjective documentation often includes opinions or perceptions related to a person’s behavior, mood, or response to care. By making it clear that the documentation is a personal interpretation, it allows others who read the notes to understand the context and the perspective from which the observations were made. This clarity in communication is essential in fields such as direct support, where understanding the nuances of an individual’s experience can significantly impact the care and support provided.

Other choices, while relevant to documentation standards, do not capture the essence of subjective documentation specifically. For instance, stating that it follows organizational policy or is a standard procedure pertains more to objective documentation or established guidelines. Thus, emphasizing that it is a personal interpretation aligns closely with the nature of subjective documentation.