Language in medical records may be due for an update

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Language in medical records may be due for an update
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Medical lingo helps shape the care and treatment patients get, and the push for more transparency is fueling a reevaluation of the words doctors and nurses use in medical records.

or "the patient denies" can sound judgmental or doubtful of patients, researchers from The Healthcare Improvement Studies Institute in the U.K. said.

"One patient stated: 'I did not deny these things. I said I didn’t feel them. Completely different. Language matters,'" the authors wrote about one person's response shown a doctor's notes of an outpatient visit. Another patient balked at the phrase “Patient claims pain is 10/10” instead of “patient experiencing 10/10 pain” because it implied a degree of disbelief, the researchers wrote.

One study cited in the analysis looked at language examples such as "not tolerating oxygen mask" versus "refuses oxygen mask" and showed the non-neutral term was linked with negative attitudes toward the patient and less prescribing of pain medications."Much of the language highlighted here is deeply ingrained in medical practice and is used unthinkingly by clinicians. However, we believe that it is now outdated," write the University of Cambridge researchers.

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