Closely following the requirement for your records to be legible is that the language is understandable. You may find it challenging to consider the abbreviations you use and how well they are understood.
You must always be careful what you write in your patient records – I’d like to think that goes without saying. Personal comments about patients, even abbreviated, must be written in a manner that would not cause offence.
What abbreviations are you using? Can they be understood?
Is your language consistent within your notes?
Your notes may be completely understandable to you but what about your colleagues within your practice, the profession as a whole or other healthcare professionals. A common language framework is important to improve understanding across healthcare and avoid abbreviations which are meaningless or could be misinterpreted by others.
A lot of work is being done internationally on clinical language. This is to improve continuity of care for patients, communication between healthcare practitioners and to improve audit, data analysis and research.
SNOMED-CT – international healthcare language
This system of international healthcare terminology is called SNOMED-CT (Systematized Nomenclature of Medicine – Clinical Terms) and has been adopted by the NHS as a compulsory language being implemented in Primary care since April 2018. They use it for coding symptoms and diagnosis in a standardised method. If you want to work within the NHS it is important to be aware of this language. Using common language where possible will aid consistent communication with other healthcare professionals.
The Chartered Society of Physiotherapy has developed a subset for SNOMED for physiotherapy language. It is well worth looking at this list – available here. Being aware of the common terminology that is being used will help you to adapt your clinical language as appropriate. For example, lateral flexion is used instead of side bending, always thoracic spine not dorsal, reflexes are referred to as knee, biceps, triceps, ankle etc. You may find a valuable CPD exercise in identifying areas for change in your notes.
Periodically reviewing your patient records can help to ensure you are maintaining good standards. Improvements can often be made each time you review your records.