Language in Patient Records Can Convey More Than Medical History

What type of language did you find that questioned patient credibility?

There were several types of language patterns that suggested the clinician might disbelieve the patient report. Some implied lack of patient competency to remember and convey accurate information. Others questioned the patient’s sincerity.

Words that implied doubt included “apparently,” “supposedly,” “claims,” or “insists.” Here are a couple of examples:

  • “Apparently he was sitting at home on the floor feeling fine when suddenly he felt fatigued all over his body.”
  • “The patient insists she gets sick from vaccines.”
  • “He claims that nicotine patches don’t work for him.”

The use of quotation marks can sometimes be interpreted as questioning the legitimacy of the quoted text. This tactic is sometimes called a “scare quote,”4 which signifies that a term being used is misleading. In one example, a physician wrote that the patient “takes albuterol for ‘chronic bronchitis.’” The quotation marks cast doubt upon the diagnosis of chronic bronchitis and also suggest that the patient has inaccurate beliefs about her condition.

What type of language did you find that conveyed disapproval of the patient?

Disapproval was suggested by terms that highlighted poor patient reasoning, decision-making, and behaviors, such as adherence or poor self-care. For example, ”she has stopped eating fruit in the last month because ‘it could have killed her’”—again, the quotation marks suggest that the patient’s health beliefs are unorthodox, or she is overreacting. Stating that a patient has “neglected to refill her blood pressure medication” is different from stating simply and neutrally that the patient has not taken her blood pressure medication.

Lastly, physicians sometimes used language that implied that they had to engage in tiresome repetition of some sort, for example, “I again explained…” or “despite repeated counseling…”

How were racial and/or social class stereotyping conveyed through the language you found in patients’ records?

These types of stereotypes were most often conveyed through direct quotes of either African American vernacular English, incorrect grammar, or nonstandard oversimplified medical term. For example, one clinician quoted the patient as stating that a surgical bandage had gotten “a li’l wet.” Another said the patient states that the lesion “busted open.”

What type of language portrayed a “difficult patient?

Some of the details suggested that the patient was ignorant, temperamental, or conveyed the physician’s frustration with the patient or the language was condescending or emotional (eg, “the patient was adamant” or “this seems to pacify him”).

How did the language convey unilateral decision making on the part of the physician?

In particular some language was paternalistic, with phrases such as, “I have instructed her” or “she was told to discontinue” or “I impressed upon her the importance of…” Phrases like these perpetuate the image of a power dynamic in which the physician presumes authority and portrays the patient as childish or ignorant.

Several of these language patterns involve the use of quotation marks. How do you think quotes should or should not be used in medical records?

I don’t come down on either side of the equation—“never use quotes” or “always use quotes.” If you do use quotes, make sure that your rationale is solid. For example, it is not only reasonable but extremely helpful to include the patient’s direct description of pain: “crushing chest pain,” “or “the worst headache I ever had.” These rapidly convey the suspicion that the patient might have a heart attack or subarachnoid hemorrhage. But stating that a lesion ruptured is different from quoting the patient stating that the lesion “busted open,” which offers no medically relevant information.

There is no simple formula for when and how to reword a direct quote. But a good rule of thumb is to ask yourself, what will show the most goodwill and respect toward the patient? How would you want someone you loved to be quoted and documented? The issue isn’t about policing language but rather putting care and respect into the records so that the next person who reads that record will regard the patient as someone to be respected and valued.

It helps to convey context for a patient’s refusal to adhere to a treatment plan. For example, writing, “She persevered on the fact that ‘a lot of stuff is going on at home with my family’ but that ‘you wouldn’t understand’” implies that this is a difficult patient. Providing some context or stating that the patient is experiencing home stressors that affect her ability to be adherent to her treatment regimen does not carry that implication. 

I think that in psychiatry, it is often more necessary to quote the patient’s actual words, especially when you are conducting a mental status evaluation. But even in that setting, the important question is whether the quote you are using is conveying medically relevant and useful information.