1/14 *TWEETORIAL 4 New Interns*
WORDS MATTER!
Non-stigmatizing medical documentation
Your admission/progress notes can be harmful to your patients and will live in the medical record system forever.
Here are some tips. Please add so we can learn to together! #MedTwitter
WORDS MATTER!
Non-stigmatizing medical documentation
Your admission/progress notes can be harmful to your patients and will live in the medical record system forever.
Here are some tips. Please add so we can learn to together! #MedTwitter
2/14
Use patient-centered language: your patients are more than their illness.
“patient with sickle cell disease” *not* “sickle cell patient” and *definitely not* “sickler”
@brighamchiefs
@DrWilfredoM
Use patient-centered language: your patients are more than their illness.
“patient with sickle cell disease” *not* “sickle cell patient” and *definitely not* “sickler”
@brighamchiefs
@DrWilfredoM
3/14
Don't put a patient’s race or socioeconomic status in their one-liner.
The one liner is for highly relevant clinical info that allows other clinicians to understand what is going on, and, in emergencies, make quick, critical decisions.
@aaronLberkowitz
@michellemorse
Don't put a patient’s race or socioeconomic status in their one-liner.
The one liner is for highly relevant clinical info that allows other clinicians to understand what is going on, and, in emergencies, make quick, critical decisions.
@aaronLberkowitz
@michellemorse
4/14
Try not to say a patient “states” or “reports” a symptom (especially pain), in the HPI.
The HPI is a patient’s subjective experience. If the patient says he is in 10/10 pain, then you write: “Patient is in 10/10 pain.” — You can be objective in the exam portion.
@ETSshow
Try not to say a patient “states” or “reports” a symptom (especially pain), in the HPI.
The HPI is a patient’s subjective experience. If the patient says he is in 10/10 pain, then you write: “Patient is in 10/10 pain.” — You can be objective in the exam portion.
@ETSshow
5/14
Beware of quotation marks.
She has had “stressful situations” - uses the patient’s language against her and undermines her experience.
Can still be appropriate e.g. an experience best said in the patient’s words: She feels like “there is a golfball stuck in [her] throat.”
Beware of quotation marks.
She has had “stressful situations” - uses the patient’s language against her and undermines her experience.
Can still be appropriate e.g. an experience best said in the patient’s words: She feels like “there is a golfball stuck in [her] throat.”
6/14
Don't write that a patient “refuses”
Instead, say they are “not tolerating” their facemask. If that doesn’t work, try “declined” or “chose not to accept" instead: “He declined antibiotics overnight, but might be amenable in the AM.”
@drlouiseivers
@colleenmfarrell
Don't write that a patient “refuses”
Instead, say they are “not tolerating” their facemask. If that doesn’t work, try “declined” or “chose not to accept" instead: “He declined antibiotics overnight, but might be amenable in the AM.”
@drlouiseivers
@colleenmfarrell
7/14
Don’t write “non-compliant”
Say the patient struggled to stick to (or adhere to) the treatment plan.
@SuzanneKovenMD
Don’t write “non-compliant”
Say the patient struggled to stick to (or adhere to) the treatment plan.
@SuzanneKovenMD
9/14
Don’t write “failed a treatment”
Because really, the treatment failed the patient.
Write, “the patient did not improve with…”
@gradydoctor
@CPSolvers
Don’t write “failed a treatment”
Because really, the treatment failed the patient.
Write, “the patient did not improve with…”
@gradydoctor
@CPSolvers
10/14
Patient’s don’t “complain”
They come with their symptoms to you as a doctor, asking for help.
@FutureDocs
@pedsmd2b
Patient’s don’t “complain”
They come with their symptoms to you as a doctor, asking for help.
@FutureDocs
@pedsmd2b
12/14
Don’t say that a patient is “clean”
Say they are not taking drugs.
@arghavan_salles
@aoglasser
Don’t say that a patient is “clean”
Say they are not taking drugs.
@arghavan_salles
@aoglasser
13/14
gold standard test:
-read carefully what you’ve written
-ask yourself if you were a patient reading your own medical chart (since that is a possibility) how would you feel about what's written
If it sounds uncomfortable, remove it.
@AmyOxentenkoMD
gold standard test:
-read carefully what you’ve written
-ask yourself if you were a patient reading your own medical chart (since that is a possibility) how would you feel about what's written
If it sounds uncomfortable, remove it.
@AmyOxentenkoMD
14/14
This tweetorial is based on things I've learned from incredible colleagues @BrighamWomens , personal experiences, and several online sources, most especially this must-read @JournalGIM article:
link.springer.com/article/10.100…
This tweetorial is based on things I've learned from incredible colleagues @BrighamWomens , personal experiences, and several online sources, most especially this must-read @JournalGIM article:
link.springer.com/article/10.100…
