Are You Using the Correct Language in Your Documentation?
Published: 12 March 2017
Published: 12 March 2017
With the advent of e-health and the digital hospital, every word we write about our patients is potentially searchable in an indelible trail of communication.
Codes of conduct often target use of the mediums through which we communicate, yet ironically we probably have less control than ever over where our words end up.
Instead, focus on the words on the screen and page, and what they say about your attitudes and personal interactions.
Despite the profusion of mediums and platforms, the number one rule of writing remains: who is my audience?
Steering a course through this correspondence battleground often depends on where you work. If it’s a large health service or hospital, it’s likely you’ve got access to a gamut of guidance: in-house style guides, correspondence and report templates, plus communication officers to advise on protocol and style.
However, if you’re in a small GP surgery or residential aged care facility, chances are you’ve only got your predecessor’s examples. If you’re learning by imitation, you’re potentially perpetuating the same mistakes.
If anything, all the recent technological changes have done is stretch the range of what is permissible. Writing sits on a spectrum of formal to informal.
Blurring occurs when medium and message get mixed up.
For example, the instantaneity of emails means we often don’t think about their content as much as a letter than has to be printed and posted.
Who hasn’t intended to reply confidentially to one person and accidentally hit the ‘reply all’ tab?
However, emails remain legal documents that reflect their author’s intentions.
Writing in a conversational style that includes slang and text-speak derivations may be acceptable - LOL, OMG and FYI have entries in the Oxford Dictionary - but be mindful that fashionable word use changes quickly and may be ambiguous or even unintelligible in a short space of time. To an older generation, LOL means ‘lots of love’.
At the opposite end of the scale, avoid anything that is offensive, whether it’s sexist, racist, ageist or homo/transphobic. That should be obvious.
However, healthcare has a long history of warped humour using acronyms and slang to poke humour at both practitioners and patients (Dragonqueen n.d). Practitioners argue this shorthand helps them cope in a high-stress industry. Some of it inevitably ends up in patients’ records.
Reading their compilations, some were laugh-out-loud funny. Or should that be LOL funny?
Others betrayed a profound disrespect for the circumstances of certain cohorts of patients, especially the homeless and those on the social fringes.
Humour is entirely subjective. Use it wisely, stay out of earshot, and only use officially sanctioned lists of abbreviations when annotating records (Australian Commission on Safety and Quality in Health Care 2016).
The dissolving boundary between how we speak and how we write adds to the blur.
When we speak, vocal nuances help shape our message: inflection, pitch and volume, alongside the subtleties of body language. When we write, our words have to perform all these actions.
Grammar is the road map of writing through which we signal to the reader how we’ve chosen to help them find their way around what we’ve written (Petelin 2016).
At its most basic, we understand how to break our writing into bite-sized chunks or paragraphs, preferably covering one concept or idea at a time. Within these blocks are sentences that ideally contain ‘things’ (nouns) that have something ‘done’ to them (verbs).
We place these ideas in a logical order - maybe chronologically, geographically, or order of importance - and bolt them into a genre, or form that best fits our message.
However, even grammar is not concrete.
The recent shift from prescriptive grammar -’you must write this way!’ - to descriptive grammar means that rules are changing, often in response to majority usage.
To older nurses, it has diminished the value of rote-learned spelling. Ditto all that precision with punctuation.
Don’t despair! Even though the spell-check generation might not get it now - imagine the outcome if the patient had ‘feinted’ in the above example - grammar is coming back into fashion in schools. Soon a new generation of nurses will understand the value of being able to parse a sentence and conjugate a verb. Everyone’s communication will be clearer - and safer - because of this.
Until that time, you’re welcome to commit random acts of punctuation violence (Truss 2006): keep a Nikko marker handy in your nursing kit; when no-one’s looking, replace all those missing possessive apostrophes on official signage. Just make sure you get it right.
Despite the wholesale shift in language use, it remains the little things that matter most to our patients.
For example, while we may focus on the purpose of their visit, acknowledging their identity via accurate titles is crucial to establishing trust; single words can make or break a therapeutic relationship.
When caring for First Nations patients, it might be acknowledging someone as ‘Aunty’ in a letter - rather than the standard ‘Mrs’ - to affirm their respected standing as an elder within their community.
For patients from culturally and linguistically diverse backgrounds, it might be worth using plain language, so the essence of your clinical instructions post-surgery can be more readily translated into their first language.
And for patients from LGBTQIA communities, it could be even more subtle. You could consider marking a patient as ‘single’, being extra sensitive to the confidentiality of information when that person is not ‘out’.
For patients comfortable with acknowledging their sexuality, you could use neutral relationship terms like ‘partner’ or even ‘spouse’, as opposed to the heteronormative ‘husband’ and ‘wife’.
Finally, for transgender patients, the simple act of correctly gendering them - regardless of what is on their birth certificate - can mean the world of difference to how they feel while in your care.
So when you’re next writing up your notes, ask yourself: what’s in a word?
Andrew Blythe is a writer and editor who has a Masters of Writing, Editing and Publishing from the University of Queensland. In addition, he is an adjunct research fellow at Griffith University within the School of Human Services and Social Work, assisting the school with both curriculum review, and lived-experience research development. He enjoys communication in all its forms and has prepared and presented material via print, including as former editor of Time and Place (the Queensland Heritage Council magazine) and Queensland Pride, as well as radio, television and multimedia formats. He is currently writing a memoir about his father’s experience of receiving a heart transplant, as well as documenting other peoples’ experiences of the Queensland health system. See Educator Profile