From Documentation to Communication: Rethinking Language in Clinical Notes - Report - MDSpire

From Documentation to Communication: Rethinking Language in Clinical Notes

  • By

  • Brianna A. Green

  • Felisha Gonzalez

  • Joann G. Elmore

  • June 29, 2026

  • 0 min

Share

Clinical Report: Transforming Clinical Notes and Patient Communication

Overview

The study highlights the impact of language in clinical documentation on patient perceptions. Traditional medical jargon is often poorly received, leading to confusion among patients, while plain language is preferred for clarity.

Background

Medical documentation has evolved from a tool for clinician communication to a resource accessible by patients due to the 21st Century Cures Act. This shift necessitates a reevaluation of language used in clinical notes.

Data Highlights

No numerical data or trial results were provided in the source material.

Key Findings

  • Traditional medical jargon is poorly received by patients.
  • Patients prefer language that is clear and respectful.
  • The study's participant demographic may limit generalizability.
  • Efforts to modify ingrained language patterns in clinical documentation are necessary.
  • Medical schools should consider incorporating patient-centered language training.

Clinical Implications

Clinicians should consider the language used in clinical notes to improve patient understanding. Modifying documentation templates can be a practical step toward improving communication.

Conclusion

Future efforts should focus on adapting clinical documentation to enhance patient communication.

Related Resources & Content

  1. Allen et al., Transforming Clinical Notes, 2023 -- Study on Language in Medical Documentation
  2. JMIR Medical Informatics — Clinical Note Generation From Doctor-Patient Conversations Using Parameter-Efficient Fine-Tuning Large Language Models: Comparative Study
  3. npj Digital Medicine — Enhancing clinical documentation with voice processing and large language models: a study on the LAOS system
  4. npj Digital Medicine — Exploring the Untested Hazards of AI Scribes in Healthcare Settings
  5. Journal of Medical Internet Research (JMIR) — Personal Health Large Language Models and the Negotiation of Medical Authority in Clinical Care: Opportunities, Risks, and Governance
  6. Information Blocking - ONC - Office of the National Coordinator for Health Information Technology
  7. Effective Patient-Physician Communication | ACOG
  8. Patient-Clinician Communication: ASCO Guideline Update - PubMed
  9. Plain Language Materials & Resources | Health Literacy | CDC
  10. 45 CFR Part 171 | Information Blocking | eCFR.io
  11. Ambient AI Scribes in Clinical Practice: A Randomized Trial - PMC
  12. Language in Birth Clinical Notes Associated With Race and Ethnicity
  13. A Proof-of-Concept Study for Patient Use of Open Notes with Large Language Models - OpenNotes

Original Source(s)

From Documentation to Communication: Rethinking Language in Clinical Notes

  • by Brianna A. Green, Felisha Gonzalez, Joann G. Elmore

  • June 29, 2026

Related Content

Case Report Describes Possible Betahistine–Suicidality Link

A single case report described suicidal ideation that resolved after betahistine discontinuation and recurred after rechallenge, but the findings cannot establish causality or quantify risk.

Dr. Jordan Strom on ASE 2026 Scientific Sessions: AI, Access, and the Future of Echocardiography

As ASE convenes its 37th Scientific Sessions near Denver, the meeting will spotlight echocardiographic AI and big data, contrast-enhanced ultrasound, evolving guidelines, the Feigenbaum Lecture, and the future of the sonographer workforce.

Where Are Adults Getting Sunburned?

Water-related activities were the most commonly reported setting for recent sunburn, while more than one-half of respondents reported sunscreen use at the time of their most recent sunburn.