Writing with care: Word choice matters in medical records and reports

In brief

• Medical records may be viewed by other healthcare providers, patients, lawyers, and insurance companies.
• When describing patients and their reasons for seeking care, ask yourself if your language is mindful and considerate.
• State known facts, try to avoid terms that might offend the patient or anyone else accessing the record, and try to frame issues in ways that are empathetic and non-judgmental.
• For disability claims or custody and access issues, state the facts about your patient’s condition objectively and avoid personal opinions and conjecture.

Think about the terms you are using

There may be times when your choice of words in a medical record or report can lead to outcomes you did not anticipate. For example:

• A patient needs a note so that they can go on sick leave from work. Visibly distraught, they tell you about difficulties they are having with their manager. You write the note, saying the patient suffers from stress due to ongoing work problems and “harassment by their manager.” The patient gives the note to their employer, who then shows the manager. The manager complains to the College.
• A patient tells you about their frequent alcohol and drug use. Planning to move to another province, they ask for a copy of their medical records. When they receive the records, they see entries in which you refer to them as being a “partier.” They complain about this to the College.

One document, many uses

College policies, legislation, and regulations in each jurisdiction outline physicians’ obligations concerning medical records, such as the type of information that must be recorded and the need for all entries to be legible.

Medical records are not only accessible to healthcare providers. Patients are generally entitled to view and obtain a copy of their medical record (either by submitting a request to their healthcare provider or through a patient portal). Records may also be requested by third parties such as lawyers and insurance companies. With the patient’s consent or other legal authorization, physicians may release copies of a medical record to these parties.

Word choice and tone

Physicians may choose to use various methodologies and formats, such as the Subjective Objective Assessment Plan (SOAP) format, to help ensure entries are sufficiently detailed and presented in a standardized manner. While SOAP or other formats may be beneficial, try to apply an appropriate tone and choose words carefully.

When describing individual patients, assess whether the terms you use might offend the patient or others reading the record, and try to frame issues in ways that are empathetic and non-judgmental.

• State only known facts and be mindful when describing characteristics such as age, gender, race, religion, sexual orientation, or gender identity.
• Avoid subjective descriptions about appearance (attractive, leggy) and do not make inappropriate comments about weight (plump, hefty). Terms like these can be considered discriminatory, and might discourage a patient from seeking care.
• Put the patient first wherever possible. For example:
• “patient with a mobility impairment” (not “disabled patient”)
• “the patient consumes cocaine” (not “the patient is an addict”)
• “patient with alcohol use disorder” (not “alcoholic patient”)
• Use quotation marks when writing verbatim statements made by patients or others.
• Respect the expressed wishes of patients and use gender-appropriate pronouns.

Disability claims, divorce and parenting arrangement issues

Physicians provide written statements in response to many situations, such as patient disability claims, and divorce and parenting arrangement (custody and access) matters.

When seeking a disability claim, patients may feel frustrated with their insurance company or employer, and may turn to you for help. Patients’ frustration can heighten if they think your letter does not provide sufficient information or support the claim. Explain to the patient the extent and nature of information you are able to provide in the written statement.

• Claims assessors need factual information about patients’ conditions, while employers may simply need to know whether patients are fit or unfit for work. Seek clarification of the third party’s information needs. State the facts about patients’ conditions objectively and avoid personal opinions and conjecture.

When dealing with divorce and parenting arrangement issues, information is typically provided to physicians by one spouse or one of the child’s parents.

• When documenting conversations in the context of a divorce or parenting arrangement issue, include the source of the information to help maintain objectivity. Limit your opinions to your area of medical expertise, especially when discussing parenting capability or choices.

Changing the content of a medical record

If you need to make a change to a medical record, be aware of the applicable regulations and guidelines published by your College. Corrections should be made only to your entries to improve clarity or accuracy. Such changes should be dated and signed or authenticated electronically, while the original entry remains intact.

Avoid making changes or adding new information to an entry after becoming aware you are the subject of a College complaint or legal action. Contact the CMPA if you have questions about making modifications to a medical record.

Additional reading

• Preparing treating physician reports and IME reports
• Did you know? You need authorization to provide medical records to lawyers
• The medical record: A legal document — Can it be corrected?
• CMPA Good practices: Documentation and record keeping

DISCLAIMER: This content is for general informational purposes and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. Your use of CMPA learning resources is subject to the foregoing as well as CMPA's Terms of Use.