As an attending and the program director in a university practice, I have the opportunity to read a lot of notes that other people have written. Many of these notes are written by residents and fellows, often from my own program. In doing so, I often come across a phrase in the opening line of a note that really irritates me, which might go something like this:
“Mrs. Smith is a very pleasant 54-year old woman who…”
Why does this bother me, you might ask?
- It immediately imparts a connotation in the note that this patient’s symptoms are to be “believed”, as opposed to other, less “pleasant” patients. The doc is probably going to be more inclined to help this patient. I explained to one trainee that I thought it should be changed in her future notes, and I explained why. Her explanation was that it was a “code” for her to remember that the patient was easier to deal with than many other patients she often sees in her practice. You can imagine how I took to that explanation…
- It implies that other patients are less pleasant. This same trainee uses “very pleasant” and “pleasant” in various notes. I sometimes wonder what it means if she doesn’t put either in the note.
- A patient’s consultation or progress note, and for that matter, the opening sentence in such a note, is not meant to be where a doctor imparts their values and judgments on the patient. Pleasantness (or perceived pleasantness) is really the patient’s affect. Therefore this descriptor really belongs best in the exam, if anywhere at all.
Other words are similarly inappropiate in this context; the word that most frequently comes to mind is “unfortunate”.
“Mrs. Smith is an unfortunate 54-year old woman…”
Although it may seem that you are empathizing with the patient, I doubt that a patient would want to actually see a doctor write in their note that they are “unfortunate”. The consequence of their problems may be unfortunate, but not the patient him or herself.
By no means do I intend to say that this issue is confined to trainees; I see the same descriptions among seasoned physicians. My best explanation for this is that no one really ever went over their notes, or that they were just never told to change it. If you find yourself saying this is your own notes, ask yourself why…and consider omitting it next time.
Gut Check Blog 
As a patient, I dread seeing such judgement calls – good or bad – in my notes. As a massage therapist, we’re trained not to let it into our notes at all. Strange Eh?
Well, I can understand where you’re coming from, but it’s certainly nit-picking. I leave myself “clues” all the time in my notes so I can go back months or years later – and know who or what I was dealing with. It works.
I have read your blog on “dificult patients”, and unfortunately, not all patients are pleasant. In fact, I thought of you last night when I was operating on a patient, and I got a message into the or from the patients family that if did one thing or another they would sue me. People I had never met.
Use whatever term you want, but there are certain patients that have to be approached in different ways. Leaving clues about these interactions in your notes to help refresh yourself later is smart medicine.
Thanks for the comment Lee…since when did you know me to be nit-picky??
I agree; I too leave myself clues, and not all patients are pleasant or easy to deal with. I still think it’s important to keep certain things in the right places in the chart…and some out completely.
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I agree whole-heartedly with this post. You are not being nitpicky. You are being wise. To excuse the use of rude and potentially dangerous descriptors as being necessary reminders is wrong. If one has the brains for medicine, they can remember which patients require the moset patience without insulting them in the chart.
In fact found this discussion prompted me to write a “comment” here that grew into a post! Launguage Matters: http://wp.me/p1gKVu-9r The effect of negative descriptors on patient care
Thanks for the great writing!
Whatever you do, please don’t say “regular rate and rhythm to auscultation.” You can’t possibly tell as much with your ears. As far as the “pleasant patient…,” it doesn’t bother me. “Unfortunate patient,” however, is unprofessional.
I enjoyed your post. I still remember a comment from 30 years ago saying that I was a very pleasant somewhat obese woman. As if that was necessary!
Thanks for the comment.
Thank you for the post, doctor.
As a patient treated for advanced ovarian cancer the first time I saw “a pleasant 44-year-old woman” in progress notes, I laughed. I am anything but pleasant. I am a pushy, sarcastic know-it-all and have a morbid sense of humor. Second time, “a pleasant 44-year-old woman” coming from another consulting doctor, I felt like there was a secret lingo. What else are those people hiding from me? They have not called me “unfortunate” yet. Them’s fightin’ words…
Ha! Interesting to hear you say this about, well…yourself!
I have heard people say they call everyone pleasant, and their own codes are to use “very pleasant” for those about whom they actually mean it.
Thanks for the comment.
Got it. I will strive for “very pleasant” or even “charming” in the autopsy report.