I was out all last week on a long trip with my family and took a hiatus from posting. I am glad to be back in the clinic and in my usual routine. The evolution of Electronic Medical Records (EMRs) has drastically changed the landscape of medical documentation. What was once an internal tool for healthcare providers, primarily used for clinical communication, billing, and legal documentation, is now easily accessible to patients through patient portals. While this increased transparency fosters patient engagement, it also presents challenges, particularly in how we, as oncology providers, craft our clinical notes.
The Shift in Medical Documentation
Traditionally, our documentation was intended for fellow medical professionals. We used medical jargon, shorthand, and terms designed for efficiency and accuracy in clinical decision-making. However, now that patients and their families can readily access our notes, it’s crucial to reconsider how we write. What was once purely for peer-to-peer communication now has a broader audience, including patients who may not have medical training but are deeply invested in their care.
It is important for patients to understand that medical documentation serves multiple purposes beyond their personal review. Our notes must also:
- Communicate Key Medical Findings to Our Peers – Medical documentation ensures accurate clinical decision-making among healthcare providers, facilitating seamless transitions of care and collaboration.
- Provide Legal Documentation – Notes serve as a legal record to demonstrate that standards of care were met and that pertinent issues were addressed with the patient.
- Support Billing and Coding Requirements – Proper documentation ensures that healthcare facilities receive timely and appropriate payments for services rendered—helping to sustain critical resources, including staff, technology, and even keeping the lights on and the AC running.
A recent article in The New England Journal of Medicine highlighted how patients react to their own medical records on social media platforms like TikTok. Many patients express frustration or distress over language that seems judgmental, impersonal, or stigmatizing. Oncology, given its emotionally and physically complex nature, must be particularly sensitive to how we document our patient interactions. The language we use can shape a patient’s perception of their illness, treatment, and overall relationship with their care team.
Words Matter: Oncology-Specific Considerations in Documentation
As oncologists, we must ensure that our notes are not only clinically accurate but also respectful and considerate of the patient experience. I will be the first to admit that I have been guilty of using language that, while medically appropriate, may not have been the most patient-friendly. We all have room to improve, and being more mindful of our words is an important step. There are some key considerations when documenting:
- Avoid Judgmental Language
Patients often feel scrutinized when they read words like “non-compliant” or “refused treatment.” Instead, consider framing it as: “The patient expressed concerns about chemotherapy and is seeking additional information before proceeding.” This acknowledges their perspective rather than placing blame.That said, if a patient is blatantly non-compliant with their medical care to the point that it poses a significant risk to their health, documentation must reflect this reality. From a medical-legal standpoint, it is essential to clearly state non-compliance when it could lead to serious harm. This not only ensures accurate communication among healthcare providers but also serves as a protective measure to highlight potential risks and avoid litigation. Transparency in documentation is critical, but it should always be balanced with respect and patient-centered communication. - Use Neutral Descriptions for Physical Attributes
Physical descriptions should be clinically relevant and avoid subjective or stigmatizing terms. Rather than labeling a patient as “obese,” which can carry negative connotations, use objective measures and clinical relevance: “Patient’s BMI is 32, which may impact chemotherapy dosing and cardiovascular risk.” Similarly, avoid phrases such as “patient is non-compliant with weight management” and instead document patient challenges and efforts: “Patient reports difficulty with dietary changes and is exploring additional support for weight management.” Using neutral, fact-based language ensures clarity while maintaining respect for the patient’s experience. - Be Cautious with Prognostic Language
Oncology care often involves discussions of prognosis, and while it’s critical to be honest, wording matters. Instead of writing “poor prognosis,” consider “The patient has a serious illness with a guarded prognosis, and we are focusing on optimizing quality of life.”When meeting patients for the first time, I often document “treatment intention” as being either curative or palliative. For patients well known to me, where trust has been established, they understand that my goal is always to provide hope and to utilize all available treatments for long-term disease control. However, when circumstances shift, it is equally important to be clear and honest about the direction of care. Transparency fosters trust and ensures patients and families are fully informed while maintaining a compassionate approach. - Use Empathetic Language When Discussing Treatment Decisions
When documenting a patient’s choice to discontinue treatment, rather than stating, “Patient declined further chemotherapy,” consider, “After discussing risks and benefits, the patient has opted for supportive care, prioritizing comfort and quality of life.” This approach respects patient autonomy while avoiding unintended negative connotations. - Clarify, Rather Than Imply Doubt, in Symptom Reporting
Terms like “patient claims” or “patient insists” can inadvertently imply skepticism. Instead, document patient concerns objectively: “The patient reports ongoing fatigue, which impacts daily activities.” This validates their experience rather than casting doubt.This is especially true for cancer survivors, who often experience lingering symptoms that can provoke anxiety about recurrence. Every symptom they report deserves careful evaluation. If no evidence of recurrent disease is found, I often reassure patients by saying, “Today is a good day—we didn’t find anything concerning, but let’s keep an eye on the symptom and follow up closely over time.” If symptoms improve, it’s a relief for both patient and provider. However, if something concerning emerges later, patients appreciate that their concerns were taken seriously from the beginning rather than being dismissed outright. - Be Mindful of Stigmatizing Terms in Cancer-Related Behaviors
Patients who smoke, drink alcohol, or have lifestyle factors contributing to their diagnosis often feel judged. Instead of “Patient continues to smoke despite counseling,” reframe as, “The patient is aware of the risks of continued smoking and is exploring cessation options.” - Consider the Emotional Impact of Chart Language
Words like “futile” or “failed treatment” can be deeply discouraging. Our patients do not fail treatments—rather, it is our treatments that may fail them. Instead of “Patient has failed multiple lines of therapy,” consider “Prior treatments have not provided sufficient disease control, and we are exploring alternative options.” This small shift in language acknowledges the effort and resilience of patients while maintaining accuracy and medical clarity.
Striking a Balance Between Clinical and Compassionate Documentation
The goal is not to sugarcoat medical realities but to ensure that our documentation is clinically sound while also being sensitive to the fact that patients and families are reading. Oncology care is uniquely challenging because our words carry profound weight. A note written with respect and clarity fosters trust and encourages open communication.
As we continue to navigate the transparency of EMRs, oncology providers should take an active role in shaping documentation practices that serve both medical and patient-centered needs. By making small yet impactful adjustments in our language, we can enhance the patient experience without compromising clinical accuracy.
About the author
Dr. Sajeve Thomas is a distinguished medical professional and a compassionate guide in the field of oncology. With over a decade of dedicated experience as a board-certified medical oncologist/internal medicine specialist, Dr. Thomas has become a trusted expert in the treatment of melanoma, sarcoma, and gastrointestinal conditions. He brings a wealth of expertise to the complex and challenging world of oncology.
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