Avoiding Racist and Judgmental Clinical Documentation: Helping to Achieve Health Equity

A patient files a complaint with hospital administration after reviewing his electronic health record through the patient portal. His new primary care physician began his documentation by describing the patient as a “55-year-old African-American male with uncontrolled blood pressure due to noncompliance with medical care.” The patient had recently started a new job and could not pay for his prescriptions because his health insurance coverage had not taken effect yet. The patient did not attend follow-up visits and a recommended cardiology consultation because he could not afford the copayments for the visits. The patient identifies as Dominican Hispanic, not African American, and feels he was being stigmatized for his race and socioeconomic status and was a victim of stereotyping and racial bias.

Medical education teaches that documenting the history of the present illness begins with age, race, and sex.¹ However, this documentation approach has been associated with negative effects on patient care, leading to stereotyping and bias in medical encounters.^1–3 Clinicians receive inconsistent education on how documentation of race affects clinical decision-making.^1,3 Historically, the use of racial categories was based on the mistaken belief that there are inherent biologic differences among races. It is now understood that these differences are predominantly the result of structural racism instead of biology.^4–6

The 21st Century Cures Act, which mandated that patients have unrestricted access to their medical records, has brought increased attention to clinical documentation. Inappropriate documentation can be perceived by patients and families as offensive and judgmental and can have negative effects on future patient participation in shared decision-making.^6,7 In a 2018 study of nearly 23,000 patients, 1 out of 10 respondents reported feeling judged or offended by something they read in their outpatient notes due to their perception that it contained errors, surprises, labeling, or evidence of disrespect.⁷ Patients who identify as Black are more likely than those who identify as White to have comments using negative words or connotations in their history and physical documentation and may be subject to systemic bias in physicians' perceptions of their credibility. This “testimonial injustice” is a potential mechanism for racial disparities in the quality of health care.^8,9

The stigmatizing language used to describe patients in medical records can influence other clinicians and physicians-in-training in their attitudes toward the patient and their medication-prescribing behavior.¹⁰ This is an important and potentially damaging pathway by which bias can be propagated from one clinician to another.¹⁰ Stigmatizing language in the electronic health record may alter treatment plans, transmit biases between clinicians, and alienate patients.^11,12

Inequitable access to high-quality health care in the United States is the direct result of structural racism in health care policies. The COVID-19 pandemic highlighted and exacerbated the fact that racial and ethnic minority groups are often devalued, disempowered, and denied equal access to essential medical resources.¹³ One of the most visible inequities is in health insurance coverage. The federal government has acknowledged that “inadequate health insurance coverage is one of the largest barriers to health care access, and the unequal distribution of coverage contributes to disparities in health.”¹⁴ Most people in the United States continue to access health care through employer-sponsored insurance; however, many people from racial and ethnic minorities are employed in low-wage jobs that do not provide adequate health insurance.¹⁵