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June 2015

Political Correctness of Medical Documentation

Author Affiliations
  • 1Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Neurol. 2015;72(6):624-625. doi:10.1001/jamaneurol.2014.4535

Having relocated to a new academic institution, I was certain that I would have to learn some new things but revising how I wrote the history and physical examinations of my patients was hardly anticipated. The template I used was largely unchanged in more than 4 decades and it had served me well.

While discussing a complex patient with one of my esteemed colleagues, he expressed his opinion that it was inappropriate to include terms describing the patient’s race/ethnicity or country of origin in the medical documents. He regarded it as antiquated and reflective of having practiced in the South. On the contrary, although I had practiced in Kentucky and the very far south—Miami, Florida—the template I had used for writing a history and physical examination was learned in Philadelphia, Pennsylvania, the same city to which I had relocated.

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