Documenting a patient encounter—whether you're a medical assistant, nurse, physician, or whatever—demands objectivity and professional language.
Consider this notation in a patient's chart: "Patient became rude, difficult, and uncooperative."
Those three words (adjectives, in this instance) are dripping with bias, like frosting on a warm cinnamon bun. (Ooh, yummy!)
Who's to say what's "rude" or "difficult"? Maybe the patient considered himself standing up for his rights, that he was being assertive, not difficult.
Using words that contain inherent bias may work well for a novel but are completely out of place in a medical record. They open the healthcare professional to charges of unprofessionalism and inappropriate patient care.
There's a simple test for determining whether a word or group of words carries bias. Ask yourself, Can someone argue with this?
Let's say you're a student who notices strange trembling in a patient's hands. You go to your instructor and say, "Ms. Jonquin's hands are tremulous."
That's a good word because no one could argue that your observation is correct. Sure, your instructor could check Ms. Jonquin and make a more accurate observation, such as, "You're right, she's tremulous. But do you see her fingers? They look like they're rolling a pill. That's called pill-rolling tremors, a classic sign of Parkinson disease."
Those words are more accurate, but so is your word, tremulous.
But you'd better believe she would argue with your word choice if you charted, "Ms. Jonquin is scared because her hands are shaking."
"Scared" is a judgment you're bringing to the situation, not something you observed.
Similarly, words such as angry, upset, sad, or any other term describing an emotion (unless the patient says it herself) are judgments about a set of objectives observations. Anyone could argue with words like those, just as they could argue with these words: attack, threaten, argue, scream, and yell.
Stick with words of objectivity that no one could argue with, that no one could contradict.
Take great care in using words that could be considered inflammatory, lest you find yourself on trial without a tremulous leg to stand on.