Tag: clinical documentation bias

Provider Track: Would you want these words in your permanent record?

Disclaimers.

Professional Standards and Scope:

• Credentials and expertise: Dr. Stephanie Michelle Nixon is a PhD-level Speech-Language Pathologist and consultant.
• Educational purpose: The content in this series is shared for informational, educational, and advocacy purposes only.
• No clinical relationship: Engagement with this content does not constitute medical advice, a clinical diagnosis, or the establishment of a patient-provider relationship.
• Medical consultation: Always seek the advice of your physician or other qualified health providers with questions regarding a medical condition.

Personal Narrative & Data Integrity:

• Designated Record Set: This series represents a personal, professional audit of my own legally obtained medical history and “Designated Record Set”.
• Factual Basis: All clinical data points—including the 169.4-minute gastric emptying result —are pulled directly from my documented clinical records.
• Advocacy Intent: My goal is to highlight systemic disparities in medical documentation and foster better clinical communication.
• Non-Defamation: This audit is a critique of the content and quality of documentation and the patterns of clinical bias, rather than an attack on specific individuals or institutions.

A Note on Neurodivergent Baseline:

Contextual Accuracy: Observations regarding communication style, energy, or behavior (often labeled “manic” or “pressured” in my records) must be viewed through the lens of my documented, lifelong ADHD diagnosis.

A ‘u’ was added (AuDHD) as a late diagnosis a few years ago providing a key to understanding why so many providers saw ‘manic’ behavior where there was actually just a neurodivergent person managing a health emergency. We have to stop labeling what we don’t understand.

medical gaslighting and the importance of accurate, data-driven medical records for neurodivergent (AuDHD) patients." class="wp-image-967" srcset="https://nixonspeechandlanguage.com/wp-content/uploads/2026/05/Case-Study-Bias-in-chart-notes-1024x1003.png 1024w, https://nixonspeechandlanguage.com/wp-content/uploads/2026/05/Case-Study-Bias-in-chart-notes-300x294.png 300w, https://nixonspeechandlanguage.com/wp-content/uploads/2026/05/Case-Study-Bias-in-chart-notes-768x752.png 768w, https://nixonspeechandlanguage.com/wp-content/uploads/2026/05/Case-Study-Bias-in-chart-notes-1536x1505.png 1536w, https://nixonspeechandlanguage.com/wp-content/uploads/2026/05/Case-Study-Bias-in-chart-notes-2048x2006.png 2048w" sizes="(max-width: 1024px) 100vw, 1024px" />

Clinical documentation is a record of pathology, not a character assessment. Yet, after auditing my own medical records, I found decades of “subjective” notes that had nothing to do with my physiological state and everything to do with a provider’s snap judgement and dismissal of my lived reality.

It doesn’t matter if a provider feels these words “justified” in the moment. Once they are in the patient’s chart, they become a permanent filter for every provider who follows.

The words on the black and white side minimize and dismiss both objective findings and my symptoms.

In the image above, a provider documented that my degree of disability ‘surpassed objective findings.’ In doing so, they failed to recognize my functional reality: I was a Speech-Language Pathologist unable to see my patients for 3 weeks after losing my voice to an ulceration on my vocal fold. When documentation focuses on ‘surpassing findings’ but ignores a total loss of vocational function, the clinical record is incomplete. We must document the patient’s life, not just the provider’s impression.

The Scope-of-Practice Gap:

I found repeated psychiatric judgments—labels like ‘pressured speech’ and ‘somatization’—written by specialists who were not psychiatrists or behavioral neurologists. Labeling a communication style as ‘pressured speech’ without establishing a neuro-informed baseline (AuDHD) isn’t just a misinterpretation—it is a specialist overstepping their scope to pathologize a natural speech rate instead of investigating physical health.

What they called “pressured”:

• A Neurodivergent Baseline: If anyone had paused to ask, I would have laughed and told them that I had the words “SLOW DOWN!” in bold on every note for every presentation during my post-graduate education.
• Physiological Distress: Rapid speech and “short rushes” are frequently associated with shortness of breath. Documentation that reaches for a psychiatric label while a patient is in respiratory distress is a failure of clinical reasoning.
• Fluency Dynamics: As an SLP, I recognize these patterns as potential symptoms of cluttering among other speech and language disorders.

None of these clinical presentations require a mental health diagnosis. When we reach for mental health labels to describe a fast speech rate, we ignore the very real physical or fluency-based realities of the patient standing in front of us.

The “Incidental” Dismissal

I once had a specialist (not a gynecologist or GI) dismiss my appendectomy as “incidental” to my laparoscopy for Stage IV extra-pelvic endometriosis. When a pathology report confirms ‘Appendix – Endometriosis,’ that appendectomy is a diagnostic data point, not an ‘incidental’ event. Labeling it as such signals to every future provider that the patient’s surgical history—and their reported pain—is irrelevant.

The Receipts:

• The Science: A 169.4-minute gastric half-time (normal is <90) was dismissed by a specialist who was “not convinced.”
• The Paradox: A 65% O2 saturation reading was recorded alongside a note that I was “well-appearing”. (Note. The 65% O2 reading was likely associated with PVCs based on the other data in the visit.)
• The Shorthand: A systemic crisis involving a 20-lb weight gain and pitting edema was labeled “long story typical for Stephanie”.

The Challenge:

• The Mirror Test: If you were the patient, would you want a crisis described as “typical” for you?
• Stay in Scope: If you aren’t a psychiatrist, why are you reaching for psychiatric labels to describe a patient’s communication? (Also, check with the patient. Had that provider asked me, I would’ve laughed and told her that my rate of speech has always been fast…in fact, I must actively think about it to speak more slowly.)
• Watch for Bias: Literally watch for it. If you see a dismissive note from a colleague, don’t carry it forward. Check the data, ask the patient, and document the objective truth.

Let’s hold the record to a higher standard. How can we ensure our “Subjective” notes don’t do lasting harm?