DECONSTRUCTING PROGRESS NOTES IN PSYCHIATRIC SETTINGS

The purpose of this article is to examine the language by which nursin g staff described these patients in their medical records, Charts of f ormer psychiatric patients were studied for the quality of the words u sed to communicate about patient behaviors, More than 4,000 entries we re examined and descriptive words that appeared with most regularity w ere presented to a panel of expert psychiatric nurses who were asked t o a sort them as to connotation, Results show that nurses entries focu s on patients in judgemental and unflattering ways. Recommendations ar e made to replace the use of negatively laden language and labels with descriptions in more behavioral and operational terms. Copyright (C) 1997 by W.B. Saunders Company.