Patient Preferences for Plain-Language Alternatives to Medical Jargon in Clinical Notes

Background

Patients are increasingly able to access their medical records, in part due to legislation mandating this access in the USA. Many terms used in medical documentation can be confusing or perceived as offensive, risking damage to the patient-clinician relationship; little evidence exists to guide alternative phrasing.

Objective

To identify adults’ preferences between traditional medical phrases and plain-language alternatives in clinical notes.

Design

A cross-sectional observational survey at the 2023 Minnesota State Fair.

Participants

Electronic surveys were offered to adults (≥ 18 years old) who spoke or read English and did not have formal healthcare training.

Main Measures

We described nine clinical scenarios and offered documentation choices using medical jargon or plain-language. We collected participants’ preferred documentation option and associated free-text comments.

Key Results

In total, 276 respondents were recruited; 271 fully completed the survey. The mean age was 45 years; 56% were women, and 67% had a bachelor’s degree or higher. Traditional medical phrases were highly unfavored compared to plain-language alternatives, including “failed outpatient treatment” (2%) vs. “did not improve” (70%); “refused antibiotics” (6%) vs. “preferred to skip” (43%) or “declined” (43%); “denies alcohol use” (16%) vs. “does not drink alcohol” (82%); and “chief complaint” (20%) vs. “reason for visit” (79%). “Non-compliant” and “non-adherent” were equally disfavored (2% each) vs. “has been unable to take” (56%) and “stopped taking the medicine” (39%). Eight qualitative themes were identified: (1) clear and thorough communication; (2) objective and accurate information; (3) direct and concise messaging; (4) empathetic, personal, and affirming language; (5) respect for patient autonomy and agency; (6) financial sensitivity in documentation; (7) recognition of patient dependency; and (8) maintenance of a formal, professional tone.

Conclusion

Our findings highlight a strong preference for plain-language in medical documentation, along with identifying a number of preferred alternative plain-language phrasing options.