Date of Award
Medical Doctor (MD)
Auguste H. Fortin
Patients are increasingly provided facilitated access to their medical notes. Physicians have reported concerns that patients will find notes confusing and offensive, and that typographical errors will appear unprofessional. This exploratory study quantifies the prevalence of potentially confusing or offensive medical language and typographic errors within inpatient notes. The authors performed a retrospective, cross-sectional review of 400 inpatient History and Physical notes from a tertiary care center. All notes were from admissions to general internal medicine services. Words and phrases of interest were codified into five pre-established categories. The authors analyzed 231 hospitalist and 106 resident notes. The most prevalent characteristics identified per note were General Medical Acronyms (99.1%), Medical Jargon (96.7%), and Typographical Errors (49%). Residents used a greater absolute number of acronyms and abbreviations (p<.01). When adjusted to a standardized note length, hospitalist notes contained more Medical Jargon and Typographical Errors (p<.05). All subdivisions within Subjective Descriptors and Mental Health & Sensitive Health Status appeared in less than 20% of all notes. While the place of medical shorthand, jargon, and sensitive history in the medical note is unlikely to change in the near future, this study identifies typographical errors as a modifiable area for improvement. The examination of medical note language may prove beneficial to the patient-physician relationship in the digital era.
Lee, Eric H., "Patient-Centric Medical Notes: Identifying Areas For Improvement In The Age Of Open Medical Records" (2017). Yale Medicine Thesis Digital Library. 2141.