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Pearls


How to use patient-centered language in documentation

During psychiatric documentation, consider using language you would like used to describe yourself or a loved one

Vol. 10, No. 10 / October 2011

Discuss this article at www.facebook.com/CurrentPsychiatry

As psychiatric care transitions to using electronic medical records, providers should be aware that patients—and their legal representation— have increasing access to their medical records. Use of patient-centered, nonjudgmental language will better preserve the physician/patient alliance.

Consider the type of language you would find acceptable in documents describing the care provided to you or a loved one. Whenever possible, describe behavior by using objective and phenomenological terms. Nothing is sacrificed by replacing words that carry a negative connotation with less charged words. However, it is acceptable— and can add to the evaluation—to quote the patient’s own words.

The Table below lists alternative terms and phrases for use in psychiatric documentation.

Table

Nonjudgmental language for psychiatric documentation

Language with negative connotation

Patient-centered language

Promiscuity

Impulsive sexual behavior

Self-mutilation

Nonsuicidal self-injury

Manipulative, ‘gamey’

The patient sought to meet their need of… (or describe specific behaviors)

Refused medication

Declined or chose not to accept medication

Nasty, rude, mean

The patient used offensive language. The patient behaved in an aggressive manner by…

Trigger

Prompt

Demanding

Made repeated requests

Noncompliant

Did not adhere to the treatment plan

Frantic, desperate

Urgent, acute, demonstrated intense feelings of…

Disturbed, dysfunctional

Dysregulated, difficult to manage

Needy

Sought reassurance

Failed medication trial

Treatment with this medication was not associated with improvement

Shopping spree

Impulsive spending behavior

The patient complains of…

The patient reported…

Drug binge

Heavy substance use over a short period

Disclosure

Dr. Nelson receives grant research/support from the Minnesota Medical Foundation.

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