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"Dijo que podía tomar su propio consejo:" Estigmatizar el lenguaje en las notas que documentan las descargas en

Judith B Vick¹, Matthew Kelly², Amanda McArthur²

¹Department of Medicine, Yale University, New Haven, Connecticut, USA.

Journal of hospital medicine

|September 4, 2025

Resumen

La documentación médica para pacientes que se van contra el consejo médico (AMA) a menudo contiene lenguaje estigmatizante y refleja dinámicas adversarias entre clínico y paciente. Se necesita claridad sobre la documentación adecuada para estas descargas controvertidas.

Área de la Ciencia:

Análisis de la documentación médica
Estudios de alta de los pacientes
Investigación en comunicación clínica

Sus antecedentes:

Las descargas en contra del consejo médico (AMA) están relacionadas con resultados negativos de los pacientes y el estigma.
La investigación previa se centró en los factores del paciente, descuidando la dinámica clínico-paciente en las descargas de AMA.

Objetivo del estudio:

Para analizar la documentación clínica de las hospitalizaciones que terminan en alta médica.
Examinar tanto el contenido como el tono de las notas médicas con respecto a las descargas de AMA.

Principales métodos:

Descripción cualitativa utilizando el análisis temático inductivo.
Análisis de 185 notas de texto libre de los servicios de medicina interna en un centro médico académico urbano.
Período de estudio: 2017.

Principales resultados:

Observa con frecuencia el conocimiento documentado de la salida del paciente, las razones de la salida, la respuesta clínica y la capacidad del paciente.
Evidencia de relaciones adversas entre el médico y el paciente, incluyendo lenguaje estigmatizante e insinuaciones de carácter.
Algunas notas exhibían neutralidad, mientras que otras contenían un lenguaje parcial o defensivo.

Conclusiones:

Los registros médicos para los alta de AMA a menudo incluyen un lenguaje estigmatizante y reflejan posturas paternalista o defensivas del clínico.
Las conclusiones ponen de relieve la falta de directrices claras para documentar las descargas AMA controvertidas.
Se necesitan mejores prácticas de documentación para evitar el estigma y el sesgo de los pacientes.

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