Ok, a couple things bothered me today, and they had nothing to do with patients smoking and drinking too much and expecting me to cure them from their self –induced destruction with a pill or with surgery. No, au contraire. It had to do with stupid words health care professionals use in charts and it bugs me enough to bloviate about it.
Word #1: Verbalize. Example: “Mr. Smith VERBALIZED to this examiner that his chest pain only occurred when he would tense down during a bowel movement.” No, the patient sure as hell did not verbalize to you, Mr. or Ms. Health professional – just say it in proper English and we will still think you are quite special. I really don’t think you’re smarter by writing those words in the chart, and the lawyers who are licking their chops to make some money on you don’t care either. Or do you think verbalizing is a more eloquent way to describe how a patient talks? Does that mean the words floated out of his mouth like butterflies searching for sunshine in the blue sky? Here is the proper way to write the same thing in the chart: “Mr. Smith said that his chest pain only occurred when straining during a bowel movement.” Does using the word “verbalize” make the poop less stinky? By the way, I used to be married, so I knew I was in trouble when my ex used to say, “we need to talk!” Sure isn’t as effective if she said, “we need to verbalize!”
Word #2: Articulate. Example: “Mrs. Smith articulated that her breathing only became heavy during sex with the neighbor man, and not with her husband.” Correct chart entry: “Mrs. Smith described a chest pain that only occurred during sex with the neighbor man, or, “Mrs. Smith said that her chest pain only occurs during sex with the neighbor man.” Either of the last entries are reasonable chart entries. I love nurses, my angels, but I think in nursing school they are taught to use verbalize or articulate instead of “said” or “described” otherwise they won’t pass. Problem is, these words are unfortunately seeping into physician’s notes as well and that’s because everyone knows hospitals are essentially run by nurses because basically, doctors fight too much.
Word #3, 4 and 5 are together: “delightful”, “extremely pleasant” These words are usually written by physicians who are massaging the chart the best they can because they want it to be pretty for the ravenous ambulance chasers (lawyers), or it’s simply because they are trying to show what lovely human beings and physicians they are. It’s meaningless drool.
These words bring to mind a simple analogy about when I describe to a friend that I enjoy my favorite food. “I love masticating my lobster dinner.” Wouldn’t it be more acceptable if I simply said, “I love eating my lobster dinner.”
My advice is tell it like it is but don’t give too much information: “Mr. Smith is a 65 year old patient brought in by ambulance because…” Who cares if he’s delightful, extremely pleasant or an old sour puss, you’re going to treat him with professional courtesy and with your best medical skills. Thankfully, I’m a surgeon and if a patient is verbalizing or articulating too much, I simply ask the anesthesiologist to give him the gas, put him to sleep and my scalpel does it’s work. No worries.
SRC