I honestly don't understand how one would make it through a work day in a timely fashion if they must consider the detailed substance of every office note. If you are rethinking and second guessing a multitude of phrases that you have somehow decided might be offensive or defeating for a patient, it must be a slow process. The way we all…
I honestly don't understand how one would make it through a work day in a timely fashion if they must consider the detailed substance of every office note. If you are rethinking and second guessing a multitude of phrases that you have somehow decided might be offensive or defeating for a patient, it must be a slow process. The way we all get through our day is a compilation of the habits we've developed over our professional life. In 30 years, I've never had anyone comment on "denies" or "diabetic". The medical record or office note is not a novel or inspirational essay we are writing for people. This is not a daily "affirmation" or anything that a patient should take that much from! I don't think patients gather their self-worth or identity from an office note! If you are a truly caring physician, interested in people in general, fully invested in your patient - that is what people respond to! writing "a person experiencing diabetes in an uncontrolled fashion" is no more "affirming" than "poorly controlled diabetic". "denies" is not a "charged" term - the office note is not questioning the veracity of a patient's experience - it is simply one person capturing what another is telling them, generally trying to be quite neutral.
I see this trend of doctors focusing on the minutiae of "affirming" language - lets face it: doctors are not that influential in every person's self worth on that level. Yes, a doctor who treats people with disrespect or contempt can be quite harmful. Basic medical language is not in that category.
I would say patients should be more alarmed when they read "dot phrase" templated notes with detailed physical exams that were never done and all the other "garbage" that ends up in an office note these days. Getting to this level is not something to waste time or energy on.
And aren't we on the verge of AI writing our office notes for us? As it should be. The situation we are currently in, where the physician is responsible for "scribing" the interaction between two people - what other professional situation requires that? AI should gather pertinent data in a neutral fashion, form it into exactly what is needed by each stake holder in the process and the note should be done by the time the physician and patient leave the room. THAT will transform medicine. Not doctors overthinking each descriptor and word in the office note.
In the meantime, why not just let the patient write out their part and they phrase it however they want? The speed at which medical care needs to be done these days does not leave anyone time to write out a "medical vignette" for every encounter.
Dr. H, you make a good point but I don't think the authors' intent was to advocate for scrupulous writing. Rather, to just be as accurate as possible and avoid concealment, distortion and the like.
I honestly don't understand how one would make it through a work day in a timely fashion if they must consider the detailed substance of every office note. If you are rethinking and second guessing a multitude of phrases that you have somehow decided might be offensive or defeating for a patient, it must be a slow process. The way we all get through our day is a compilation of the habits we've developed over our professional life. In 30 years, I've never had anyone comment on "denies" or "diabetic". The medical record or office note is not a novel or inspirational essay we are writing for people. This is not a daily "affirmation" or anything that a patient should take that much from! I don't think patients gather their self-worth or identity from an office note! If you are a truly caring physician, interested in people in general, fully invested in your patient - that is what people respond to! writing "a person experiencing diabetes in an uncontrolled fashion" is no more "affirming" than "poorly controlled diabetic". "denies" is not a "charged" term - the office note is not questioning the veracity of a patient's experience - it is simply one person capturing what another is telling them, generally trying to be quite neutral.
I see this trend of doctors focusing on the minutiae of "affirming" language - lets face it: doctors are not that influential in every person's self worth on that level. Yes, a doctor who treats people with disrespect or contempt can be quite harmful. Basic medical language is not in that category.
I would say patients should be more alarmed when they read "dot phrase" templated notes with detailed physical exams that were never done and all the other "garbage" that ends up in an office note these days. Getting to this level is not something to waste time or energy on.
And aren't we on the verge of AI writing our office notes for us? As it should be. The situation we are currently in, where the physician is responsible for "scribing" the interaction between two people - what other professional situation requires that? AI should gather pertinent data in a neutral fashion, form it into exactly what is needed by each stake holder in the process and the note should be done by the time the physician and patient leave the room. THAT will transform medicine. Not doctors overthinking each descriptor and word in the office note.
In the meantime, why not just let the patient write out their part and they phrase it however they want? The speed at which medical care needs to be done these days does not leave anyone time to write out a "medical vignette" for every encounter.
Dr. H, you make a good point but I don't think the authors' intent was to advocate for scrupulous writing. Rather, to just be as accurate as possible and avoid concealment, distortion and the like.