Deconstructing progress notes in psychiatric settings

Abstract

The purpose of this article is to examine the language by which nursing staff described these patients in their medical records. Charts of former psychiatric patients were studied for the quality of the words used to communicate about patient behaviors. More than 4,000 entries were examined and descriptive words that appeared with most regularity were presented to a panel of expert psychiatric nurses who were asked to Q sort them as to connotation. Results show that nurses entries focus on patients in judgemental and unflattering ways. Recommendations are made to replace the use of negatively laden language and labels with descriptions in more behavioral and operational terms. Copyright © 1997 by W.B. Saunders Company.