Should organizations address stigmatizing language in medical records? 

That is the question posed by Lisa A. Eramo, MA in her article “Choose Your Words Carefully” in a recent edition of For The Record. “Words matter. It’s not only what you write but also how you write it that affects others. This is true in a variety of settings, and health care is certainly no exception. In fact, a recent study conducted by researchers at Johns Hopkins University School of Medicine (Journal of General Internal Medicine, May 2018) found that the words providers document in patients’ medical records affect how other clinicians perceive and ultimately care for those patients—and not necessarily for the better.

‘I think sometimes we consider the medical record as a collection of objectively recorded data and plans, but when you step back, it becomes clear that you can really shape the narrative about a patient in very different ways, both implicitly and explicitly,” says Anna Goddu, MD, lead author and a medical student at Johns Hopkins University.’ ”

For real-world insight into how word usage and stigmatizing language in patient health records affect provider perception, Eramo tapped Intellis HCC experts Kim Felix, RHIA, CCS, vice president of education and training and Jeanie Heck, CCS, CPC, CRC, director of education. Kim addressed examples of stigmatizing language. Further, she supported creating an atmosphere where CDI specialist feel safe flagging stigmatizing language and alerting risk management or quality assurance. Jeanie addressed the need to maintain professionalism and emphasized mandatory education to ensure less experienced staff understand the importance of appropriate language.

The full article is available in For the Record.