Words are powerful and influential, not only when spoken, but when written.  As healthcare professionals, we must be diligent to use non-stigmatizing and non-biased language in our medical record documentation. I recently read a health record that documented a patient encounter that clearly conveyed the personal (negative) opinion of the health staff member about the patient and his presenting complaint.

Please read the following: 

“Patient is 38-year-old black male who came to the medical unit via wheelchair after he allegedly had a seizure and fell off the top bunk.  He is an opiate and benzodiazepine addict, long term, with at least four failed rehab attempts in the last two years.  He supposedly had a seizure and rolled off the top bunk and is now demanding pain medication.  He admits to trying to get “anything” (drug) from cellmates, but “no one had anything” to help him with his detox. Right now, he has only mild symptoms that are not even bad enough to warrant the comfort medication available under the protocol. He is drug seeking and nothing will be ordered at this time per the provider.” 

There was no physical assessment done, and no plan and no patient education documented. 

As the next health professional to see the patient in clinic (for whatever reason), do you have preconceived notions (bias) of the patient after reading this entry in the health record?  Should you have them?  How could this information have been presented in a more neutral, non-stigmatizing manner? 

Interestingly, research conducted by Yasgur and Goddu, et al indicated that the use of stigmatizing and biased language in a health record resulted in a reduced level of pain medication being prescribed for patients, and in general, conveyed the health professional’s attitude towards the patient.  If the attitude was negative, which it often was, the potential for stigma and disparate care was heightened. 

In our next post, we will discuss the words in this encounter documentation that imply bias and stigmatize the patient, and in our third post on this subject, we will discuss an example of how the documentation could have been written to eliminate the biased and stigmatizing language and the physical evaluation that should have been done.

How can this be applied to your correctional nurse practice? Please remember to always check your words.  Are they unbiased? Do they convey the facts in a neutral way, and do they convey the situation without extraneous information unrelated to the current encounter?   

This post is taken from the February 2022 edition of The Correctional Nurse Newsletter. If you haven’t already subscribed, I invite you to do so….there is no charge and your information will never to be given/sold to anyone else!