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Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

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What Should Students and Trainees Learn About Patient-Centered Documentation?

Nubia Chong¹, Maria Mirabela Bodic², Peter Steen³

¹Psychiatrist working for a group practice in Washington, DC.

AMA Journal of Ethics

|March 6, 2024

Summary

Clinicians should use person-centered, trauma-informed language in patient records. This approach avoids paternalistic terms that can demean patients and promotes respectful, neutral clinical documentation.

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Area of Science:

Medical Ethics
Health Communication
Patient Advocacy

Background:

Clinical documentation significantly impacts patient well-being and experiences.
Paternalistic language in health records raises ethical concerns, highlighting power imbalances and potentially causing patient distress.
The use of demeaning or traumatizing language in medical notes is a critical issue.

Purpose of the Study:

To emphasize the importance of person-centered and trauma-informed language in clinical documentation.
To advocate for documentation practices that ensure clinical neutrality and respect for patients.
To provide strategies for educating future healthcare professionals on appropriate documentation.

Main Methods:

Literature review on clinical documentation standards and ethical considerations.
Analysis of the impact of paternalistic versus person-centered language on patient experience.
Development of pedagogical strategies for teaching respectful documentation.

Main Results:

Paternalistic language in clinical notes can be demeaning and traumatizing for patients.
Person-centered, trauma-informed language is crucial for ethical and respectful patient care.
Educational interventions can effectively teach trainees neutral and respectful documentation practices.

Conclusions:

Adopting person-centered, trauma-informed language in clinical documentation is essential for ethical patient care.
Healthcare education must prioritize teaching documentation that upholds patient dignity and avoids harm.
Shifting towards neutral and respectful language enhances the therapeutic alliance and patient safety.