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Use of Language in Patient Medical Records

This morning I chanced upon a tweet about a recently published JAMA article –

It was a qualitative study of clinical encounter notes, that looked at both the positive and negative ways physicians express their feelings toward patients. There were 5 major themes for negative language:

  1. questioning patient credibility: “The patient claims …”
  2. expressing disapproval of patient reasoning or self-care: “Despite repeated counseling …”
  3. stereotyping by race or social class
  4. portraying the patient as difficult: “The patient was adamant…”
  5. emphasizing physician authority over the patient: “I have impressed upon her…”

The six themes representing positive language included:

  1. direct compliments: “The patient is charming…”
  2. expressions of approval: “The patient is knowledgeable about her medication.”
  3. self-disclosure of the physician’s own positive feelings toward the patient: “She is pleased with this development, as am I.”
  4. minimization of blame: “very pleasant male with multiple barriers to accessing care…”
  5. personalization: “She is active … and likes to travel.”
  6. highlighting patient authority for their own decisions: “She will consider…”

Let’s this discuss this journal article at the #HealthXPH tweet chat 9 pm Manila time, 17 July 2021.

T1. Have you seen stigmatizing language in patient medical records. Give examples.

T2. Give examples of positive language used in patient medical records.

T3. Comment on the study’s conclusion:

“… language could potentially transmit bias and affect the quality of care that patients subsequently receive… increased physician awareness when writing and reading medical records is needed to prevent the perpetuation of negative bias in medical care.”

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