This exploratory mixed-methods study examined language used in 161 clinical notes selected from a random sample of 300 notes at a perinatal substance use disorder clinic. Researchers identified stigmatizing terminology alongside both patient-centered and non-patient-centered wording. Language patterns varied with several patient and care characteristics, including age, prior cesarean delivery, prenatal care quality, and time since conception. The authors developed a chart-note assessment tool and emphasize the importance of respectful documentation, particularly as patients increasingly read their own records through online portals.
