Had a patient ask me to explain my notes and I realized how much jargon I use

Last Thursday this older guy pointed at my charting on his discharge summary and said "what does any of this mean?" I tried to explain it but even I was tripping over the words. Made me rethink how I write things up. Anyone else simplify their notes after something like this happened?

2 comments

2 Comments

wesleypatel1mo ago

Oh man, does that hit close to home? I had a similar thing happen a few months back when a patient's family member asked me to read my notes out loud. I literally could not get through a sentence without stopping to translate my own writing. It was SO embarrassing. After that I started putting little plain English summaries at the end of each note. Nothing fancy, just a sentence or two that says what I actually found and what we're going to do about it. It's made a HUGE difference for me and honestly for the patients too. They actually understand what's going on now.

mason_jackson1mo ago

Totally agree with you @wesleypatel. I started doing the same thing after a nurse caught me writing "pt c/o SOB" and asked if it meant "short of breath" or something else. I put a one or two sentence summary at the end of my notes now too. It saves me from having to translate everything later and patients actually nod along instead of looking confused. The best part is it takes maybe 30 seconds extra per note. Small change, huge payoff.