In a previous post, I shared an example of real charting that clearly included language that could be considered stigmatizing and biased, and today I wanted to review the words that make it so.   Here is the progress note:  

 “Patient is a 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 his cellmates to help with the detox, but “no one had anything” that could help. 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 seekingand nothing will be ordered at this time per the provider. Mr. Jones was very angry when he left the medical unit.” 

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

Which words and actions imply bias and stigmatize the patient? 

Black – Although I was taught somewhere along the line to include a patient’s race in my note, it is now considered potentially racially biased.  I see the point, especially since we typically have racial data in our health record elsewhere that we can access if necessary.

Allegedly – This implies that you disbelieve his statement that he had a seizure and fell off the bunk.  Instead, using words like “reported” or “stated” makes it a neutral statement.  

Addict – This is a dated and prejudicial term; instead, use person with a “substance use disorder” or similar language.  

Long term, with at least four failed rehab attempts in the last two years – this information may be true but is irrelevant to the presenting complaint.  It may discolor our thoughts about the patient. 

Supposedly – Implies that you do not believe the patient’s report of seizure and falling off the bed for a second time in the note.

Demanding– Implies he is forcefully insisting that pain medication be given to him.

He admits to trying to get “anything” (drug) from his cellmates to help with the detox, but “no one had anything” that could help – this information may be true, but has nothing to do with a potential seizure and fall injury. Implies that he is drug-seeking.

Only mild symptoms that are not even bad enough to warrant the comfort medication available under the protocol– The author is making a decision about the severity of the symptoms without an objective measure and subjectively stating that the patient does not “even need” the comfort medications prescribed for him. Pain and discomfort are subjective conditions that we can measure objectively through pain scales and withdrawal monitoring tools like the CIWA-ar and COWS.  

He is drug seeking – The nurse is diagnosing this patient, which is beyond her/his/their scope of practice. Adding this opinion to the health record is inflammatory and potentially biases all subsequent readers of the progress note.  

Mr. Jones was very angry when he left the medical unit.- It would be better in this instance to describe the behavior exhibited by Mr. Jones, rather than label him as angry, which can be interpreted many ways. 

There was no physical assessment done, and no plan and no patient education documented – How is this biased or stigmatizing? Ignoring for a minute that all patients presenting to be seen by healthcare staff require a history of the presenting complaint (Subjective), a physical examination appropriate to the complaint (Objective), a plan (nursing and/or provider) and patient education, in this instance the nurse showed just what she thought of Mr. Jones and his “alleged” seizure and fall from the bunk by ignoring his complaint  and not even giving him the examination his history and presenting complaint required. 

In your practice, I encourage you 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? Please share your experience with biased or stigmatizing documentation in the comments area below.

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.