The Patient-Centered Approach to Medical Note-Writing

Medical chart notes have moved from the cloistered purview of clinicians into the age of transparency. The availability of electronic medical records and the enactment of federal regulations in the United States have combined to make documentation more easily accessible to patients. The writing of clinical notes, however, has not kept pace with modern expectations. Chart notes have traditionally been thought to serve the purpose of good medical communication, itself a task not always performed with success. Now, however, the ability of patients to read their own notes has brought to light the often-ignored responsibilities of also conveying humanity, withholding judgment, and being patient-centered. Many charting practices common in clinical medicine are now outdated as clinicians have reconsidered how to write notes that patients will be reading.

Virtually every part of the medical record is affected by the language used by the writer, from the very first line of a medical history to the complexities of patient preferences for testing and treatment. For example, it was once commonplace to identify a patient in racial or ethnic terms (e.g. "50 year old African-American man presents with..."), or as their disease (e.g. "60 year old diabetic") or behavior (e.g. "25 year old injection drug user") rather than as a person. Other writing practices are more subtle, including the use of stigmatizing language in the narrative (history of present illness) or the physical examination. In some cases, the stigmatizing language may reflect an internal bias on the part of the writer, while in others it may simply be unknowing connotations brought forth from a lay reader.

The clinical impact is twofold: One, charting that is not patient-centered can erode patient trust, as studies have shown that patients find certain types of language judgmental or offensive. Two, there is evidence that stigmatizing language can bias the next person who reads the chart note, thereby potentially affecting future treatment of the patient. These impacts are compounded by electronic records in which problematic language exists in perpetuity.

There is a need for a comprehensive reference on how to write medical notes in this new era. There is no current text that fills this gap. The Patient-Centered Approach to Medical Note-Writing is a vital reference for students, residents and fellows as well as medical educators while also appealing to practicing clinicians who use an electronic medical record in which patients read notes written about them.