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UCQ

Nursing Charting and Documentation

Using Bias-Free Language

Nurses' charting and documentation should be neutral and free of judgement or unproven conclusions.

Nurses' documents should include observed behavior without judgement. 

For example:

Unbiased language names the behaviour: Patient is yelling and pushing nurses away.  Patient is expressing depressive thoughts.

Biased language judges the person: Patient is aggressive. Patient is depressed.