Pearls

How to use patient-centered language in documentation

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During psychiatric documentation, consider using language you would like used to describe yourself or a loved one


 

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As psychiatric care transitions to using electronic medical records, providers should be aware that patients—and their legal representation— have increasing access to their medical records. Use of patient-centered, nonjudgmental language will better preserve the physician/patient alliance.

Consider the type of language you would find acceptable in documents describing the care provided to you or a loved one. Whenever possible, describe behavior by using objective and phenomenological terms. Nothing is sacrificed by replacing words that carry a negative connotation with less charged words. However, it is acceptable— and can add to the evaluation—to quote the patient’s own words.

The Table below lists alternative terms and phrases for use in psychiatric documentation.

Table

Nonjudgmental language for psychiatric documentation

Language with negative connotationPatient-centered language
PromiscuityImpulsive sexual behavior
Self-mutilationNonsuicidal self-injury
Manipulative, ‘gamey’The patient sought to meet their need of… (or describe specific behaviors)
Refused medicationDeclined or chose not to accept medication
Nasty, rude, meanThe patient used offensive language. The patient behaved in an aggressive manner by…
TriggerPrompt
DemandingMade repeated requests
NoncompliantDid not adhere to the treatment plan
Frantic, desperateUrgent, acute, demonstrated intense feelings of…
Disturbed, dysfunctionalDysregulated, difficult to manage
NeedySought reassurance
Failed medication trialTreatment with this medication was not associated with improvement
Shopping spreeImpulsive spending behavior
The patient complains of…The patient reported…
Drug bingeHeavy substance use over a short period

Disclosure

Dr. Nelson receives grant research/support from the Minnesota Medical Foundation.

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