The notes entered on medical records by physicians and other clinicians offer insights into their opinion about patients’ behavior and the validity of their complaints. In Massachusetts and elsewhere, the attitudes of healthcare professionals can impact the quality that patients receive. When they have negative opinions, the terminology and phrases that they use in their medical notes may correspond with insufficient medical care.
Types of negative comments in medical records
Researchers evaluating the negative and positive terminology found in medical records grouped negative or unflattering comments into five categories.
Negative comments implied:
- Doubts about patient credibility
- Disapproval of patient self-care practices
- Bias related to race or socioeconomic status
- Criticism of patient attitude
- Assertion of physician authority
Examples of negative perceptions took the form of stating that a patient was exaggerating pain or refusing to recognize a physician’s authority. Quotation marks around statements attributed to patients sometimes replicated speech patterns or grammatical errors associated with certain racial groups.
In the context of investigating a medical malpractice claim, medical records hinting at bias or disregard for information provided by patients may illustrate why complaints were not adequately investigated or treated. Medical records containing modifying words like “supposedly” or “apparently” alongside patients’ statements cast doubt on their complaints. As a result, the use of such language in medical notes could support accusations that the physician did not believe the patient or thought the person was too ignorant to understand the situation.
Unilateral decision making
Medical records can show that a physician made decisions with little consideration of a patient’s complaints. Language in the notes that demonstrates a disregard for a patient’s knowledge or needs could illustrate a physician’s dismissive attitude. The notes might say things like the patient had to be instructed repeatedly to accept the physician’s decision.