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March 13, 2013

Language in Medical Documentation

Author Affiliations

Letters Section Editor: Jody W. Zylke, MD, Senior Editor.

Author Affiliations: Virginia Tech Carilion School of Medicine, Roanoke, Virginia (Mssrs Dittman and Weller; wjdittmar@vtc.vt.edu).

JAMA. 2013;309(10):983-984. doi:10.1001/jama.2013.1001

To the Editor: A Viewpoint by Dr Wang1 encouraged readers to adopt a documentation style that would be targeted for patients' consumption. We disagree and posit that patient care would suffer.

Language is key to social cohesion, providing a foundation for communication and creating further shared experiences.2 In this way, contemporary students are initiated into the subculture of medicine by learning a shared vocabulary that describes specific physiological and psychological phenomena. Furthermore, the medical body of knowledge is expanding rapidly, thereby necessitating new words. Demands on a clinician's time require that documentation be balanced with patient encounters, education, and administrative tasks. Physicians must thus be able to rapidly and accurately communicate specific information.