Are You Using the Correct Language in Your Documentation?

7m of CPD
With the advent of e-health and the digital hospital, every word we write about our patients is potentially searchable in an indelible trail of communication. So, when you’re next writing up your notes, ask yourself: what’s in a word?

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What is this article about?

Codes of conduct often target the use of the mediums through which we communicate, yet ironically, we probably have less control than ever over where our words end up. Instead, focus on the words on the screen and page, and what they say about your attitudes and personal interactions.


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Meet the educator

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Andrew Blythe
Andrew Blythe is a writer and managing editor of QNews magazine, as well as an adjunct research fellow at Griffith University. Andrew has experience across radio, television and multimedia, as well as curriculum review and research development.
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What do others think?

249 reviews by Ausmed Learners
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Tintumol Mathew
27 Jul 2020
Good read
Samandeep Ahluwalia
25 Apr 2020
James Lloyde
20 Sep 2023
Nice information
Debra Curran
29 Aug 2021
Very interesting article to read, very well written and gave me food for thought, as I looked up the references and I learned a lot of new acronyms that ought not ever be used in patients/clients notes as is is vitally important to only ever create respectful notes on clients/patients There is a reference about patients who are comfortable with acknowledging their sexuality, and that health staff can use neutral relationship terms like ‘partner’ or ‘spouse’, as opposed to the heteronormative ‘husband’ and ‘wife. I am more than happy to go with this ; however I do find it very insulting and disturbing to be directed to now not document husband or wife and only ever refer to them as partners, as this is truly offensive to a great deal of especially older persons who regard themselves as husbands and wives and many have done so for many years and to these people to be a husband or a wife is an important title and ought be replaced by partner or spouse. Bottom Line = We need to be respectful to all persons.
Portrait of Mikal Debabe
Mikal Debabe
07 Jun 2021
Julia Taylor
20 Mar 2022
Excellent information to help in documentation
01 May 2022
Registered Nurse
Good to help in record documentation..
Portrait of Sharina Hussain
Sharina Hussain
27 Aug 2021
Useful resource for correct documentation.
Lynette Archibald
30 May 2023
Registered Nurse
Good advice and knowledge
bernie harbrow
14 Jan 2023
Registered Nurse
very important reading
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