Reclaiming the medical record for patient-centered care

Objective

This paper examines how clinical documentation in mental health settings can serve as a patient-centered tool that strengthens the therapeutic alliance, reduces stigma, and promotes equity particularly in light of expanding patient access to health records.

Methods

Drawing from empirical research and clinical practice, the discussion offers actionable strategies for creating patient-centered documentation. Key areas include language use, recognition of systemic bias, and tailored approaches for sensitive topics and minoritized populations.

Results

Adopting a patient-centered approach to documentation fosters trust, reduces stigma, and encourages shared decision-making. Transitioning from judgmental or stigmatizing language to inclusive, strengths-based, and contextually informed language can transform clinical notes into therapeutic and advocacy tools.

Conclusion

Using respectful, inclusive, and recovery-oriented language in clinical notes supports both ethical and clinical objectives, especially in mental health. Documentation not only captures patient information but also communicates values, reinforces patients’ humanity, and influences the course of care.

Practice implications

Mental health professionals can use patient-centered documentation to enhance communication, build trust, and advance health equity. By adopting mindful language and addressing systemic factors in their charting, clinicians can turn documentation into an integral part of therapeutic care.