Avoiding Ambiguous Documentation


Unclear terms can weaken medical documentation and confuse your colleagues, and this physician has had enough.

Fam Pract Manag. 2007 May;14(5):60.

As part-time medical director for a health insurer, I review mountains of medical reports and files as part of my daily duties. Often, I'm puzzled by the phrases and acronyms my fellow physicians use.

Some physicians fill their documentation with specialized, hard-to-pronounce terms such as epistaxis, spondylolysis or even mittelschmerz – words that might be useful in a spelling bee. At the other end of the spectrum are ambiguous words or phrases. Physical exam findings such as “appears anxious,” “teeth in fair repair,” “quiet precordium” or “distant breath sounds” leave generous room for interpretation. Similarly, oversimplified terms or phrases are often used to describe a patient's general appearance, such as “in no apparent distress,” “resting comfortably” or “looks stated age.” In my humble opinion, the most confusing, irksome and ambiguous phrase of all is “well-nourished, well developed.”

The phrase “well-nourished, well-developed” has reared its generically bland head all over physicians' medical documentation, from podiatrists all the way up to neurologists. What does this phrase really mean? The logical assumption is that it means “adequately fed and grown.” What other meaning can there be? Plenty, it turns out.

In my review of medical documents, I see this confusing phrase abbreviated almost always as WNWD. For example, “A WNWD patient presents to discuss obesity.” In this case, the physician seems to use WNWD to describe a patient who is approaching obesity; however, the term “overweight” would have been more helpful.

Other physicians use WNWD to describe patients with body mass indices approaching emaciation, as in “WNWD with BMI of 16.” In this case, if the person was just thin, the physician should have stated that fact. Or if the person appeared anorexic or cachectic, why didn't the physician just say so?

Still other physicians use WNWD to describe the patient who is neither excessively thin nor heavy; however, even for these patients, more descriptive terms or phrases would be more helpful.

I humbly offer a solution to the wasteful and needless use of WNWD and other ambiguous and nebulous terms and acronyms: Never use them again. At best, they add little to the general description of the patient; at worst, they can mislead physician colleagues who read or review your medical documents. When the overall nutritional status of a patient is summarized as WNWD, this might imply anything between body builder and couch potato.

I don't blame my fellow physicians for using this term. It seems to have been passed down from generation to generation, and its use was probably valid at one time. I suspect the use of WNWD blossomed in medical reports when physicians cared for sickly or malnourished people throughout the early 20th century, especially during times when diseases such as polio and tuberculosis crippled and consumed the unsuspecting public. Unfortunately, WNWD has overstayed its welcome in modern medical reports, which describe patients who are more likely to be overnourished and unhealthy. Nowadays, our public health crises usually revolve around excesses, leading to obesity, diabetes, cardiovascular disease and cancer.

For now, I am encouraging my colleagues and doctors in training to relegate WNWD to the archives of the medical lexicon and to use more descriptive terms or phrases to describe the patients we care for. From what I have seen at my institution, physicians' verbal and written skills are collectively strong and rich with finesse – certainly more than just “well-developed.”

About the Author

Dr. Grief is an assistant professor of clinical family medicine in the Department of Family Medicine at the University of Illinois at Chicago. Author disclosure: nothing to disclose.

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