| Chief complaint |
Primary concern/reason for visit instead of complaint
|
| Obesity |
Document the patient’s BMI. When needed, document obesity as a condition the patient has, not as an adjective. |
| Diabetes |
Document diabetes as a condition or diagnosis, not as an adjective (diabetic) |
| Diabetes management |
High A1c or hyperglycemia, rather than uncontrolled diabetes; A1C level is above X goal |
| Adherence |
Has difficulty with treatment plan, rather than non-compliant: describe the behavior; e.g., she takes the medication only twice a week. She worries about relying too much on a medicine. |
| Drug use disorders |
Use alcohol or substance use disorder, rather than describing patient as alcoholic, IVDU, addict; Urine tox was negative or contained no other drugs, rather than was clean or dirty
|
| History |
Does not or has not instead of denies (history of present illness is subjective/reported by its nature) |
| Gender |
Ask and document gender identity and pronouns to match patient’s expressed identity |
| Age |
Consider stating age, rather than describing patient as elderly
|
| Difference in approach |
Describe the difference and the patient’s reason: patient declines or chooses not to, or prefers not to for X reason, rather than refuses |
| Race/ethnicity |
Adopt a consistent approach, rather than one that documents race/ethnicity only when the patient is not Caucasian |
| Sickle cell disease |
Patient with Sickle Cell Disease, rather than sickler
|
| General |
Quotation marks may occasionally suggest skepticism |
