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  “The patient has lost 5 pounds and is motivated to continue this positive trend toward our goal of 20 pounds,” rather than “The patient still needs to lose another 15 lbs.”
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  “The patient chose not to pursue treatment,” rather than “The patient refused treatment.”
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  “The patient does not consume alcohol,” rather than “The patient denies alcohol consumption.”
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  Use terms that may be perceived as less judgmental or confusing:

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    “Shirt untucked” (rather than “disheveled”)
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    “Short of breath” (rather than SOB)
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    “Follow up” (rather than f/u)
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    “Right eye/left eye” (rather than OD/OS)
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    “False alarm” (false positive)
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    “Enlarged heart” (rather than “cardiomyopathy”), “chronic kidney disease” (rather than “renal failure”)

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  Turn the computer screen toward the patient to show what you are typing.
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  Check for understanding and accuracy during the visit.
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  If dictation is available, consider dictating with the patient present.
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  Consider having the patient contribute to the note, if this option is available.

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  “I want you to look at my notes and make sure we are both on the same page.”
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  “Reading your notes may remind you about what we discussed when you get home. You can also share it with your family or caregivers if you would like.”
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  Advocate to have the electronic medical record configured to automatically send reminder messages to patients after visits or prior to follow-up visits.

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  “I see us as a team working together to improve your health, so your feedback makes a big difference! Accuracy is important to me, so if you see something you think might be a mistake in your note, please let me know so we can work together to fix it.”
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  Give the patient a copy of the prior clinic note (paper or electronic) to review while in the waiting area.
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  Ask, “Did you have a chance to read my note from last visit? What questions or concerns do you have about what was written?”

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  “Thanks for pointing out that I wrote ‘right knee’ rather than ‘left knee’; I'll be sure to note the correction in your chart.”
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  “I understand you want your history of cocaine use removed from the medical record, but this information has important implications for your blood pressure and chest pain.”
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  “I'm sorry you disagree with my assessment that alcohol contributed to your fall. While I can't change my medical opinion, if you'd like I can add that you disagree with it.”