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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.
âpatient with sickle cell diseaseâ *not* âsickle cell patientâ and *definitely not* âsicklerâ
@brighamchiefs
@DrWilfredoM
Use patient-centered language: your patients are more than their illness.
âpatient with sickle cell diseaseâ *not* âsickle cell patientâ and *definitely not* âsicklerâ
@brighamchiefs
@DrWilfredoM
3/14
Don't put a patientâs 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 patientâs 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 âstatesâ or âreportsâ a symptom (especially pain), in the HPI.
The HPI is a patientâs subjective experience. If the patient says he is in 10/10 pain, then you write: âPatient is in 10/10 pain.â â You can be objective in the exam portion.
@ETSshow
Try not to say a patient âstatesâ or âreportsâ a symptom (especially pain), in the HPI.
The HPI is a patientâs subjective experience. If the patient says he is in 10/10 pain, then you write: âPatient is in 10/10 pain.â â You can be objective in the exam portion.
@ETSshow
5/14
Beware of quotation marks.
She has had âstressful situationsâ - uses the patientâs language against her and undermines her experience.
Can still be appropriate e.g. an experience best said in the patientâs words: She feels like âthere is a golfball stuck in [her] throat.â
Beware of quotation marks.
She has had âstressful situationsâ - uses the patientâs language against her and undermines her experience.
Can still be appropriate e.g. an experience best said in the patientâs words: She feels like âthere is a golfball stuck in [her] throat.â
6/14
Don't write that a patient ârefusesâ
Instead, say they are ânot toleratingâ their facemask. If that doesnât work, try âdeclinedâ or âchose not to accept" instead: âHe declined antibiotics overnight, but might be amenable in the AM.â
@drlouiseivers
@colleenmfarrell
Don't write that a patient ârefusesâ
Instead, say they are ânot toleratingâ their facemask. If that doesnât work, try âdeclinedâ or âchose not to accept" instead: âHe declined antibiotics overnight, but might be amenable in the AM.â
@drlouiseivers
@colleenmfarrell
7/14
Donât write ânon-compliantâ
Say the patient struggled to stick to (or adhere to) the treatment plan.
@SuzanneKovenMD
Donât write ânon-compliantâ
Say the patient struggled to stick to (or adhere to) the treatment plan.
@SuzanneKovenMD
8/14
Substance use disorder, *not* âaddictâ
Alcohol use disorder, *not* âalcoholicâ
@COREIMpodcast
Substance use disorder, *not* âaddictâ
Alcohol use disorder, *not* âalcoholicâ
@COREIMpodcast
9/14
Donât write âfailed a treatmentâ
Because really, the treatment failed the patient.
Write, âthe patient did not improve withâŚâ
@gradydoctor
@CPSolvers
Donât write âfailed a treatmentâ
Because really, the treatment failed the patient.
Write, âthe patient did not improve withâŚâ
@gradydoctor
@CPSolvers
10/14
Patientâs donât âcomplainâ
They come with their symptoms to you as a doctor, asking for help.
@FutureDocs
@pedsmd2b
Patientâs donât âcomplainâ
They come with their symptoms to you as a doctor, asking for help.
@FutureDocs
@pedsmd2b
12/14
Donât say that a patient is âcleanâ
Say they are not taking drugs.
@arghavan_salles
@aoglasser
Donât say that a patient is âcleanâ
Say they are not taking drugs.
@arghavan_salles
@aoglasser
13/14
gold standard test:
-read carefully what youâve 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 youâve 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: https://link.springer.com/article/10.1007/s11606-017-4289-2
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: https://link.springer.com/article/10.1007/s11606-017-4289-2
