Beyond Words: Addressing Ethical Issues in Clinical Documentation through Medical Education

Stigmatizing language in medical documentation is a barrier to achieving patient-centered care and health justice: it can contribute to patient distrust and alienation, and it appears more frequently in the charts of patients from marginalized groups, especially Black patients, impacting the future care they receive. One powerful avenue to address this issue is within undergraduate medical education; however, while some have investigated educational interventions to improve accuracy and technical proficiency in charting, there is significantly less focus on instruction surrounding the ethical and social consequences of documentation. We contend that incorporating activities designed to elicit critical thinking about language, power, and structural injustice can encourage students to reflect upon and improve their documentation practices and can arm them with a critical lens through which to view the documentation generated by their peers and preceptors as they progress through training and establish the habits that will persist throughout their careers.