Some inappropriate word choices for charting are not quite so obvious. Dr. Yore cites the phrase “frequent flier,” a common term her department uses to refer to patients who visit the emergency department regularly, often with the same complaint. “That phrase should never find its way into a chart, but it does,” she said, suggesting that writing “this patient is well known to this emergency department” would be a better choice. Along these same lines, Dr. Gowda now refrains from using certain descriptors: “For example, instead of stating that a patient is obese/overweight, I state the patient’s BMI.”

Some physicians express concerns about patients’ inability to understand the medical jargon used in charts, but “this is the age of Google,” reminded Dr. Yore. “People who are invested in their care and motivated to understand their condition can look up the terms and learn more than they would ever want. To the degree that the jargon is useful for precise and concise communication with other members of a health care team, I am okay with it.” 

Reference

1. Bell SK, Delbanco T, Elmore JG, et al. Frequency and types of patient reported errors in electronic health record ambulatory care notes. JAMA Netw Open. 2020;3(6):e205867.