Best Practices for Patient-Centered Language in Documentation

Words in the medical record shape clinical decisions and influence patients’ trust and engagement in their own care. Under the 21st Century Cures Act, patients now routinely access their own notes, making this language directly visible to them as well.

This is a living document, developed jointly by the Stanford Health Care Office of Health Equity and Office of Patient Experience, the Improvement Capability Development Program (ICDP), and the Stanford Medicine Center for Improvement (SMCI), in collaboration with patient-engaged organizations.