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Notes in a Patient’s Record Can Harm Their Treatment

Words Matter

In a 1996 episode of the hit show Seinfeld titled “The Package,” Elaine, played by Julia Louis-Dreyfus, gets a rash and seeks medical care. She peeks in her medical record (then a written document) to find that she has been labeled “difficult.” That one word stigmatizes her, ultimately preventing her from getting the care and treatment she needs.

It’s just a sitcom, but the fact remains that the words recorded in a patient’s medical record can have a significant impact on how their healthcare provider handles their care. A biased comment, an inaccurate or incomplete depiction of a patient, or worst of all, a criminalizing remark all have the potential to negatively influence a patient’s experience. As Bethany Davis writes in her article, “Derogatory Language in Charting: The Domino Effect,” making assumptions about a patient can result in “error and place the patient at risk.”

Examples of Derogatory Language

Davis’ article offers a list of words and phrases that do harm and offers a better option. For example, when a patient declines a medication because it has caused nausea or itching or some other side effect, the chart should either detail why the patient decline or say something like “not tolerating” the medication, rather than “patient refuses.” Rather than fill the chart with terms like “substance abuser,” providers should say “substance use.” Urine is not “clean” or “dirty”; urine tests “positive” or “negative.” Davis also points out slang expressions that stigmatize patients, like calling someone who seeks medical attention often a “frequent flyer.”

The Research on Stigmatizing Language

Anecdotal evidence aside, a Johns Hopkins School of Medicine study also verified the potential danger of biased documentation. Researchers created two different sets of notes for a “hypothetical patient,” one with stigmatizing language and the other with neutral language.

The findings?

Those health care providers who were given the notes with stigmatizing language proved to:

Subsequent studies reveal that stigmatizing language impacts the way physicians treat the patient, which in turn affects the patient. “Further studies have shown that medical professionals’ attitudes have impacted patients’ feelings of empowerment and action-oriented tasks.”

Suggestions for Change

Davis stresses how important it is for notations to humanize patients, so they can be seen for who they are. Perhaps even listing hobbies or interests will help healthcare providers remember they are working with a person who is a patient, not simply a patient who needs a diagnosis.

This strategy is particularly important when it comes to addressing mental health. There is a big difference between a “depressed patient” and a “patient with a history of depression. Davis explains, “Instead of criminalizing the patient and personalizing the individual to the concern, we remember that people have problems, but are not the problems.”

Furthermore, giving patients access to their medical records is also an important strategy to counter potential biased charting. This way, they can advocate for themselves, and possibly prevent misinformation or misinterpretation. Knowing that a patient will review the notes can also influence healthcare providers to approach charting through the lens of the patients they serve and “build bridges” instead of “roadblocks.”

As Davis explains, “if there is less patient engagement and less empathy because of stigma and misinterpretation through derogatory language, this is a problem of patient safety, period.” There’s no other way to say it: Words matter.

At The Eisen Law Firm, we advocate for patient safety. In fact, Brian Eisen is a board-certified patient safety advocate as well as an attorney. We are well aware of the type of care you should receive in a healthcare facility and are well versed at reading medical records. The words in your medical record matter, as does the treatment you receive. If you or someone you love has been impacted by a medical error, please contact our experienced Cleveland malpractice lawyers to discuss your options for legal recourse and for obtaining the compensation you deserve. To schedule your free consultation, call 216-287-0900 or contact us online today.

Source: https://patientsafetyj.com/index.php/patientsaf/issue/view/patientsafety-march2021/pdfpages

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