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Deconstructing progress notes in psychiatric settings

W K Mohr¹, M J Noone

¹School of Nursing, University of Pennsylvania, Philadelphia, USA.

Archives of Psychiatric Nursing

|January 7, 1998

Summary

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Nursing documentation often uses judgmental language when describing psychiatric patients. This study recommends using behavioral terms for more objective and respectful patient communication.

Area of Science:

Nursing
Psychiatry
Medical Documentation

Background:

Accurate and objective patient documentation is crucial in healthcare.
Previous studies suggest potential biases in clinical language.

Purpose of the Study:

To analyze the language used by nursing staff to describe psychiatric patients in medical records.
To evaluate the connotation of descriptive words used in patient charting.

Main Methods:

Analysis of over 4,000 medical record entries for former psychiatric patients.
Identification and Q-sort categorization of frequently used descriptive words by expert psychiatric nurses.

Main Results:

Nursing entries frequently employed judgmental and unflattering language.

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Commonly used terms carried negative connotations.

Conclusions:

The current language in nursing documentation may negatively impact patient perception.
Recommendations include adopting behavioral and operational descriptions over judgmental labels for improved patient communication.