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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.
Abstract:
What clinicians document about patients can have important consequences for those patients. Paternalistic language in patients' health records is of specific ethical concern because it emphasizes clinicians' power and patients' vulnerabilities and can be demeaning and traumatizing. This article considers the importance of person-centered, trauma-informed language in clinical documentation and suggests strategies for teaching students and trainees documentation practices that express clinical neutrality and respect.
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