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Comment & Response
November 2015

Use of Descriptive Terms in Medical Records

Author Affiliations
  • 1USAF School of Aerospace Medicine, Neuropsychiatry Branch, USAFSAM/FECN, Wright-Patterson Air Force Base, Ohio
JAMA Neurol. 2015;72(11):1378. doi:10.1001/jamaneurol.2015.2642

To the Editor I read with interest the comments by Dr Berger1 on his experience in which he was advised by a fellow academic colleague that it was inappropriate to include terms describing a patient’s race/ethnicity or country of origin in medical documentation. This guidance was undoubtedly offered with well-meaning intentions. As a neurologist who completed residency training (in Ohio) in the mid-1980s, I share Dr Berger’s amazement and dismay at receiving this advice. I completely agree with Dr Berger that having this information available in the medical record can be critical when including or excluding diagnostic possibilities and can as well be influential for individual disease management. I also agree that adding this information can help the physician to better understand each patient’s uniqueness, which, in turn, can enhance physician-patient communication.

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