Word choice and tone matter in medical records and reports
A patient seeks a note from you so she may go on sick leave from work. Visibly distraught, she has told you about the many difficulties she has with her manager. You write the note, indicating the patient suffers from stress due to ongoing problems at work and “harassment by the [patient’s] manager.” The patient gives the note to her employer, and the manager complains to the College. The College is critical of the note, stating in its review that you made remarks based solely on information given by the patient without attributing the source of the information (i.e. the patient).
Another patient who has openly shared with you his history of frequent alcohol and recreational drug consumption is preparing to relocate to another province. You provide him with a copy of his medical records as he requested. He observes entries in which you refer to him as being a “pot user” and “partier.” He complains about these characterizations to the medical regulatory authority (College). The College cautions you about your choice of language, noting that the entries in question demonstrate a lapse in professionalism.
How might you approach writing sick notes and medical record entries, and minimize the risk of misunderstandings and College complaints?
One document, many uses
In the event of a College complaint or legal action, medical records are often the best evidence in describing and defending the care provided.
College policies as well as legislation and regulations in each province and territory outline physicians’ obligations concerning medical records. For example, the College of Physicians and Surgeons of Ontario (CPSO) specifies, among other things, that medical records be legible and that they reflect every patient encounter and patient-related information. “The record must tell the story of the patient’s healthcare condition and allow other healthcare providers to read and understand the patient’s health concerns and problems.”1
Medical records are not only for the eyes of healthcare providers. Patients are generally entitled to view and obtain a copy of their medical record, and records may also be requested by third parties such as lawyers and insurance companies. With the patient’s consent or other legal authorization, physicians may release copies of a medical record to these parties.
Word choices and tone
Given the varied uses of medical records, it’s important that every entry not only describe the patient encounter accurately and reflect the physician’s thought process, but that the information is presented in a way that reflects the expected level of professionalism. Physicians may choose to use various methodologies and formats, such as the Subjective Objective Assessment Plan (SOAP) format,2 to help ensure entries are sufficiently detailed and presented in a standardized manner. While using SOAP or other formats may be beneficial, it’s important to use judgment in applying an appropriate tone and to choose words carefully.
What is an appropriate tone for a medical record? Generally speaking, it should reflect objectivity and contribute to patient and public trust in physicians and the medical profession—one that would be seen as “treating the patient with dignity and that respects the equal and intrinsic worth of all persons.”3 That trust, however, can erode quickly with just a single overly casual or misunderstood remark.
When describing individual patients and their reasons for seeking your professional services, ask yourself whether your chosen language could potentially offend the patient or others who might read the record, and what terms they might generally use to describe themselves and their situation.
- Be objective by stating only known facts and think carefully about language to describe a person’s age, gender, race, creed, sexual orientation, lifestyle, appearance, disabilities, habits, and so on.
- Avoid subjective descriptions of a person’s appearance such as “attractive,” “leggy,” “plump,” and so on. Focus your description on neutral, quantifiable characteristics and choose clinically appropriate language.
- Put the person first if possible. For example:
- “Female with mobility impairment” (not “disabled woman”)
- “Patient Y consumes recreational cannabis” (not “drug addict”)
- “Male with alcohol use disorder” (not “alcoholic male”)
- Use quotation marks when writing verbatim statements made by patients or others.
- Respect the expressed wishes of patients to use gender-appropriate terms to describe them, such as “patient” or “they.”
Disability claims, divorce and parenting arrangement issues
Physicians provide written statements in response to many other situations, such as patient disability claims, divorce and parenting arrangement (custody and access) matters.
In a disability claim, patients may feel frustrated with their insurance company or their employer, and may turn to their physician for help. Patients’ frustration can heighten if they perceive the physician’s letter does not provide sufficient information or is not supportive of the claim.
- Claims assessors need factual information about patients’ conditions, while employers may simply need to know whether patients are fit or unfit for work. Seek clarification of the third party’s information needs. State the facts about patients’ conditions objectively and avoid personal opinions and conjecture.
When dealing with divorce and parenting arrangement issues, information is typically provided to physicians by one spouse or one of the child’s parents.
- When documenting conversations in the context of a divorce or parenting arrangement issue, include the source of the information to help maintain objectivity. Limit your opinions to your area of medical expertise, especially when discussing parenting capability or choices.
Changing the content
If you need to make a change to a medical record, be aware of the applicable regulations and guidelines published by your College. Corrections should be made only to your own entries to improve clarity or accuracy. Such changes should be dated and signed or authenticated electronically, while the original entry remains intact. Avoid making changes or adding new information to an entry after becoming aware you are the subject of a College complaint or legal action. Contact the CMPA if you have questions about making modifications to a medical record.
The bottom line
- Include sufficient detail in each medical record entry so that another healthcare provider with no previous interaction with the patient could obtain the necessary information about the clinical encounter to continue providing care for the patient if needed.
- Record the information objectively and factually, being mindful of how the patient or others might interpret your word choices.
- Where practical, write medical record entries as soon as possible following each event (contemporaneously).
- College of Physicians and Surgeons of Ontario [Internet]. Toronto(CA): CPSO; 2012 May. Policy Statement 4-12: Medical Records [cited 2019 Nov 26]
- For examples of SOAP notes, see the Purdue Online Writing Lab (Purdue University)
- Canadian Medical Association [Internet]. Ottawa(CA): CMA; 2018. CMA Code of Ethics and Professionalism [cited 2020 Jan]