Documenting patient care is an important part of mental health services. The documentation is expected to be accurate, relevant, and informative for all future readers as it provides details about patients and the care they are receiving. Language can produce positive or negative emotions in individuals, and these emotions can influence their thoughts and actions. Considering this, nursing documentation can impact the future care of patients. In this study, our aim was to analyse the language and words nurses use when documenting about their patients. Through a qualitative review of notes transcribed by mental health nurses in a forensic setting (n = 55), we explored the adjectives and verbs used across a subsection of their documentation over a three-month period. More specifically, we identified the most common words used, looked for patterns in use, and examined the emotional weight - or valence - of word choice. Examination of valence scores of the adjectives and verbs in the notes indicates that while nurses describe their patients in a rather neutral manner overall, some words and phrases are ambiguous and/or repetitive, and have the potential to negatively influence the perceptions of the reader regarding the patient. Clinical implications of patient care are discussed in the context of bias management. Nurses need to consider how word choice is linked to negative prosody and the need to provide additional information to avoid ambiguity. Without such care, notes can be subject to misinterpretation by readers leading to undue labels, stigma, and bias.

译文

:记录患者护理是心理健康服务的重要组成部分。该文档将为所有未来的读者提供准确,相关且可作为参考的信息,因为它提供了有关患者及其所接受护理的详细信息。语言会在个人中产生积极或消极的情绪,这些情绪会影响他们的思想和行为。考虑到这一点,护理文件可能会影响患者的未来护理。在这项研究中,我们的目的是分析护士在记录患者病历时使用的语言和词语。通过对司法医护人员在法医环境下转录的注释进行定性审查(n = 55),我们研究了在三个月的时间里,他们文档的一个小节中使用的形容词和动词。更具体地说,我们确定了最常用的单词,寻找使用的模式,并检查了单词选择的情感分量或效价。检查笔记中的形容词和动词的效价分数表明,尽管护士总体上以中性的方式描述其患者,但某些单词和短语含糊不清和/或重复,并有可能对读者的看法产生负面影响病人。在偏倚管理的背景下讨论了患者护理的临床意义。护士需要考虑单词选择与否定韵律有何联系,以及需要提供其他信息以避免模棱两可。如果没有这样的注意,便笺可能会被读者误解,从而导致不必要的标签,污名和偏见。

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