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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 connotation Patient-centered language Promiscuity Impulsive sexual behavior Self-mutilation Nonsuicidal self-injury Manipulative, ‘gamey’ The patient sought to meet their need of… (or describe specific behaviors) Refused medication Declined or chose not to accept medication Nasty, rude, mean The patient used offensive language. The patient behaved in an aggressive manner by… Trigger Prompt Demanding Made repeated requests Noncompliant Did not adhere to the treatment plan Frantic, desperate Urgent, acute, demonstrated intense feelings of… Disturbed, dysfunctional Dysregulated, difficult to manage Needy Sought reassurance Failed medication trial Treatment with this medication was not associated with improvement Shopping spree Impulsive spending behavior The patient complains of… The patient reported… Drug binge Heavy substance use over a short period

Disclosure

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