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Comment & Response
November 2015

Use of Descriptive Terms in Medical Records—Reply

Author Affiliations
  • 1Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Neurol. 2015;72(11):1379. doi:10.1001/jamaneurol.2015.2645

In Reply I thank Dr Hesselbrock for his articulate support of my belief that medical records should include information regarding race/ethnicity and country of origin in light of its potential contribution to medical care. As he appropriately advises, these should be recorded in a nonjudgmental, nonpejorative fashion. At the conclusion of my Viewpoint,1 I challenged the readership to inform me of their perceptions regarding this issue. In response, I have received in excess of 20 emails and several text messages; most, but not all, came from academic neurologists. Some of the correspondence was from nonneurologists. All but 2 responses were extremely supportive. One responder reminded me that these elements of the history are generally considered inappropriate by journal editors in case reports unless they are germane to the condition being reported. I could not agree more with that belief; on the other hand, we are addressing elements of a confidential medical document recorded at the time of the initial patient visit when the physician may be uncertain of the diagnosis and appropriate treatment and has little familiarity with the patient. Among the comments that I received was a caution to be aware of the blowback. It was with a bit of trepidation that I initially put pen to paper for the Viewpoint1 for that very reason, but I have been heartened by the apparent alignment on this issue of so many fellow physicians.