Derogatory Language in Charting: The Domino Effect
“Dr. Smith” is meeting with a patient in Room 3 who has been admitted for abdominal pain and nausea. He suspects the patient may have appendicitis and will need her appendix removed. Dr. Smith begins to chart, “Ms. Dorian is a 34-year-old female; has a history of abusing alcohol; and is here to be consulted for an appendectomy upon admission for nausea, vomiting, and abdominal pain.”
The Room 3 nurse sits down at the computer to review Dr. Smith’s note on her patient. “Hmmm, maybe a consult for substance use would be helpful for this patient,” she thinks. The nurse puts in an electronic consult request for a social worker to meet with the patient in Room 3.
A few hours later, a unit social worker knocks on the door of Room 3. “Hello, I’m here to conduct an assessment for substance use and discuss alcohol-use resources.” The patient is holding her abdomen while she looks with wide eyes at the social worker. “I have been sober for 15 years. Why are you here?”
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Leonieke C. van Boekel, Evelien P.M. Brouwers, Jaap van Weeghel, Henk F.L. Garretsen, Stigma Among Health Professionals Towards Patients With Substance Use Disorders and Its Consequences for Healthcare Delivery: Systematic Review, Drug Alcohol Depend, Volume 131, Issues 1–2, 2013, (http://www.sciencedirect.com/science/article/pii/S0376871613000677)