When serving as an advocate for a family member, I noted judgmental language in the EHR. This reminds me as a clinician to consider how patients (and their families) will feel when they read my notes.
Words matter. As clinicians, we bear a great responsibility to ensure that words we choose are clear and nonjudgmental. As a rule of thumb, I try to think about how what I write will be received and interpreted by those who will read it.
I recently had a family member in the hospital and was given access to their medical chart to help with patient advocacy. I talked to the many specialists and consultants and asked questions during morning rounds. I also religiously read my loved one’s medical record.
The family member changed services and I, as the patient advocate and a medical colleague, asked the team about two consultant recommendations, one of which the team said was no longer of import, though it was unclear to me why. I reviewed what that recommendation had been and wanted to understand why it no longer needed to be followed. From my perspective, the two medical professionals should discuss the differing recommendation, resolve it, and document the resolution. The team agreed to confer with the other clinicians. In the chart though, the team documented that the family “insisted” the team consult with other the clinicians. Reading this note, I was irked. I felt judged for advocating for my family member’s care. I’d just wanted the i’s dotted and t’s crossed, and if it was decided this recommendation no longer was indicated, I was fine with that outcome.
Open notes in the electronic health record (EHR) have many benefits for patients becoming more actively involved as partners in care. Knowing that patients will read what we write, we must carefully consider that the words we choose are objective and nonjudgmental.
Words matter. And though it takes more time, it’s helpful to think about how you as a patient or family member would feel when reading your own or a loved one’s medical record.
This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.