Which characteristic of the PCR ensures it is not opinion-based?

• A. Accurate
• B. Timely
• C. Complete
• D. Factual

Answer: (D)

In a patient care report, the most important way to avoid opinion-based content is to keep everything factual. Factual means you record what you can verify: observable data, measurements, times, medications and doses, interventions performed, and the patient’s reported symptoms and responses. These details come from what you can see, hear, or measure, and from the patient’s own statements, not from your personal beliefs or inferences.

For example, writing that the patient reported chest pain of 8/10 at 0930, with a blood pressure of 142/88, heart rate 92, respirations 18, and aspirin given at 0935, reflects verifiable information that others can corroborate. In contrast, saying the patient is “likely having a heart attack” introduces interpretation and speculation, which is not based on observable facts and could mislead or bias future care.

While being accurate, timely, and complete are all important qualities of a good PCR, only being factual centers the report on objective information rather than opinions. This makes the record reliable, defensible, and useful for continuity of care and legal purposes.