Number
216
Name
Teaching Equitable Clinical Documentation: A Novel Curriculum
Date & Time
Sunday, June 15, 2025, 5:30 PM - 7:00 PM
Location Name
Exhibition Hall C
Presentation Topic(s)
Curriculum
Description

Purpose
The medical record presents an occasion for biases about patients to be perpetuated or dispelled by the writing physician. Transmission of bias is largely dependent on the writer’s tone which is comprised of two elements: word choice and details included. Word choice can belittle, doubt, or blame the patient. Details included can stigmatize the patient, especially if the patient’s race is listed in the one-liner or if they are unnecessarily quoted. Most physicians do not receive formal training about equitable clinical documentation. In modern practice with clinical notes not only available in litigation and to other physicians but also available for patients to review themselves, it is particularly important to document accurately and equitably.

Methods
Thus, we developed a novel curriculum to educate physicians about written tone and transmission of bias. It is comprised of two major modules about word choice and details included; both utilize interactive lessons. The first highlights common words that we use and suggests acceptable alternatives that emphasize equity. The second highlights common errors we execute and includes two sub-modules on patient race and patient quotes. The curriculum’s conclusion pauses to acknowledge a critique of political correctness that ultimately does not overcome the importance of equitable clinical documentation.

Conclusions
This curriculum is currently being finalized as the primary project for this author's work at the Harvard Macy Institute Program for Post-Graduate Trainees: Future Academic Clinician Educators. Afterward, we intend to disseminate the curriculum to fourth-year medical students. The impact of the curriculum will be additionally measured and separately presented.