Be Careful of Your Language Choices in Medical Records

April 30, 2024

Stigmatizing language in patient’s electronic health records is associated with diagnostic errors and delays in care and communication with patients and their caregivers, according to a recently published research letter. The small study found the prevalence of stigmatizing language was higher among Black patients, as well as patients with public insurance and housing instability.

The importance of sound documentation without loaded language cannot be overstated. Objective documentation is essential for capturing the patient’s complete healthcare story and providing appropriate high-quality care.

ISMIE’s resource on documentation provides an excellent overview of what you can do to ensure complete, timely and thoughtful medical records.

You may also want to review ISMIE’s FAQs on “Information Blocking” and the Release of Electronic Health Information.

For more information, please contact the Risk Management Division by email.