Which of the following is FALSE about clinical documentation?
1) Patients and families often use vague terms like 'lethargic' - MOST notes only contain these vague terms in the chief complaint or in direct quotation in the HPI - and progress to include more descriptive and clearly understood language.
2) The source of information should be recorded/included in the note.
3) The medical record reads like a story that describes what is heard, seen and includes the medical decision-making.
4) Listing differential diagnoses and reasons for diagnostic tests is necessary and more valuable to describe the clinician's thought process than a lengthy history, physical exam or list of orders.