Interpretive language
Definition
Words that assign cause, meaning, or legal category to a finding. Phrases such as 'consistent with sexual assault' or 'defensive wound' are interpretive. They belong in an expert-opinion section or in court, not in a descriptive clinical entry.
Related terms
- Addendum
- A separate, dated, and signed entry added to an existing record to correct an error or supply omitted information. It preserves the...
- Contemporaneous record
- Notes made at or very close to the time of the event they describe. Courts give contemporaneous records more weight than later...
- Objective documentation
- Recording only what can be directly observed, measured, or quoted, without inference about cause, intent, or legal category. The nurse's role is...
- SANE examination record
- The structured documentation completed by a Sexual Assault Nurse Examiner: triage, history in the patient's own words, systematic body map, specimen chain-of-custody...
- Verbatim quote
- The patient's exact words, enclosed in double quotation marks and attributed to the patient, rather than the nurse's paraphrase or summary of...
Explained in
- Forensic Nursing Documentation StandardsWords that assign cause, meaning, or legal category to a finding. Phrases such as 'consistent with sexual assault' or 'defensive wound' are interpretive. They...