What Should Students and Trainees Learn About Patient-Centered Documentation?

Abstract

What clinicians document about patients can have important consequences for those patients. Paternalistic language in patients' health records is of specific ethical concern because it emphasizes clinicians' power and patients' vulnerabilities and can be demeaning and traumatizing. This article considers the importance of person-centered, trauma-informed language in clinical documentation and suggests strategies for teaching students and trainees documentation practices that express clinical neutrality and respect.