The “pleasant” elderly gentleman who wasn’t, and the ethics of coded language in clinical documentation
I’ve read enough HPIs to recognize that when a patient is described as “pleasant”, I may find them to be anything but. I think this phenomenon is interesting because, while perhaps motivated by a genuine concern to avoid damaging the doctor-patient relationship, most would agree that including something in the note that’s not fully accurate is ethicallly questionable. But, then again, if I describe a patient as pleasant, even with full sincerity, isn’t that more a description of my own response, rather than an inherent quality of the subject? Does that mitigate the ethical breach? I’d love to hear more examples of coded language in progress notes to help me develop my ideas on the topic.