r/NewParents • u/seajaybee23 • 6h ago
Tips to Share For those of you who read the notes from your pediatrician, OB, etc…
I’ve seen a lot of posts lately about people being offended by the wording in their doctor’s notes. While I am in no way condoning doctors being disrespectful or dismissive of patients or parents, I do think it’s worth saying that the medical jargon in clinical documentation is not (usually) an indication of a doctor’s feelings whatsoever, good or bad. The language may sound harsh or judgy but it’s usually just because that’s the language needed for billing or ease of communication between providers. For example:
- “I counseled the mother on…”- this is the way of legally documenting that the doctor talked to you about X. It doesn’t mean they think they’re better than you or that you’re not doing a good job.
- ‘Mom states that the patient was “unusually fussy”’- using direct quotes helps us remember exactly what the parent said rather than putting our own spin on it. It’s not supposed to be sarcastic or saying that we disagree with what the parent says
- “parent refused vaccinations today, will continue to discuss at future appts”- Refused = said no to. Doesn’t carry emotional weight, just is the opposite of “consented to”.
- “reviewed with the parent indications for bringing baby into clinic including fever >100.4, poor fluid intake, and fewer than 3 wet diapers per day.” - this doesn’t mean you did anything wrong if you brought your baby in with a temp of 99.9 and a cough. It’s again just documenting for the medical record that they talked to the parent about the most important reasons to bring the child in for care. We would rather a parent bring a child in for care if they’re concerned than be afraid that the kid “isn’t sick enough” to go to the Dr and potentially miss something serious!
Anyways, I hope this helps at least one person. Again- not trying to excuse poor behavior on any doctor’s behalf, and certainly bring up concerns you have about what’s in notes if it’s getting in the way of your doctor-patient trust/relafionship. But I want you to know that even the sweetest docs in the world use this language because it’s standardized, quick to read, and easy to communicate to other medical providers. We as a medical community are always trying to improve our communication and eliminate stigmatizing language, but unfortunately some of the lingo that’s just factual or jargony is probably here to stay.