In recent years there’s been increasing awareness of the impact of language in healthcare documentation. And for good cause: Sometimes seemingly innocuous descriptions end up having stigmatizing effects that can negatively impact patient trust and even the behaviors of other clinicians, which leaves treatment outcomes hanging in the balance.
For ODs, precise and empathetic documentation is a must. Optometry 411 outlines some key areas to watch for, along with simple questions you can ask yourself to make sure you’re on the right track:
Recognize stigmatizing language in optometric practice
Consider the following documentation examples:
“Patient is noncompliant with contact lens hygiene.”
“Patient claims to experience visual disturbances.”
These kinds of phrases may carry unintended negative connotations. Describing a patient as “noncompliant” can imply willful negligence, while “claims” may suggest doubt about the patient’s symptoms.
Using this language can ultimately affect how you and other clinicians perceive and manage the patient’s care.
Strategies for respectful and effective documentation
By now, you’re well aware of the value of using person-first language, i.e., “patient with glaucoma” instead of “glaucoma patient.” Using person-first language in documentation originated from disability rights advocacy in the late ’80s and has since been widely supported across healthcare orgs.
It’s also important to keep your notes objective and to avoid implying doubt. Let’s go back to the examples up top:
“Patient is noncompliant with contact lens hygiene.”
“Patient claims to experience visual disturbances.”
You might replace “noncompliant” with “patient reports challenges adhering to contact lens hygiene regimen.” And rather than “patient claims,” use “patient reports” or “patient describes.”
Terms like “difficult patient” should be avoided. You want to focus on specific behaviors or concerns.
Impact of language on patient care
We don’t bring all this up to be warm and fuzzy. A study published in JAMA Network Open found that negative — often not even explicitly negative — language in medical records can transmit bias and affect the quality of care that patients subsequently receive.
Self-Check Questions for Better Documentation
✅ Am I describing the patient, or labeling them?
✅ Is my language objective and factual?
Am I documenting observations without implying judgment? (“Patient reports not wearing lenses nightly” vs. “patient is noncompliant.”)
✅ Would I be comfortable reading these notes aloud to the patient?
✅ Have I noted barriers to care rather than implying blame?
Instead of “patient refuses treatment,” consider “patient declined treatment due to cost concerns.”
✅ Am I considering cultural, socioeconomic, or personal factors in my documentation?
Does my note reflect an understanding of factors that may impact adherence or behavior?
✅ Is my documentation supporting continuity of care?
Will another provider reading this note gain a clear, unbiased view of the patient’s condition and concerns?
✅ Am I using language that promotes patient-centered care?
Does this note reflect partnership and collaboration with the patient, or does it create an us vs. them dynamic?
