Endorsement Denial

Over the past several years, the terms endorse and denies have found their way into our medical presentations and documentation. I originally saw these used in psychiatry notes, but today more frequently read them in emergency department (ED), inpatient, and discharge summaries. However, they seem quite out of place to me, since the definitions I learned growing up seem to be different than the meanings these terms convey in contemporary medical documentation.

To settle this in my mind, I decided to head to my bookshelf and dust off the old hardcover Oxford English Dictionary, arguably a standard for the English language. Endorse is defined in this dictionary as “to confirm, to declare one’s approval, or to sign/write on the back of a check or document.” None of these definitions really describe what is meant when we read endorsein the medical record. I suppose we might say to a patient, “I heard you’re having abdominal pain,” and they may respond with, “yes, that is true.” In this case, they would be confirming our statement and thereby endorsing it. But that is not the way we conduct most medical interviews. If we are asking open-ended or yes/ no questions as we were taught, then our patients will rarely respond in a manner that would be considered endorsing their symptoms. Or consider this example: I once read “the patient endorses wearing a seatbelt.” Actually, so do I! I think it’s a great idea and has been shown to save lives. But in the context of this particular medical record, I understood the author to be indicating that the patient was wearing a seatbelt themselves at the time of their motor vehicle crash. In light of this definition in the Oxford dictionary, we should ask ourselves whether our patients really endorse their symptoms? I might endorse a political candidate or endorse a policy statement. I may even endorse a check. But I do not endorse a symptom and I suspect our patients do not, either. If we substitute the definition for the word endorse, it does not make sense: “the patient supports a facial droop” or “the patient confirms diarrhea.” These are cringeworthy at best and awkward and inaccurate otherwise. Even more inelegant is the negative: “the patient does not endorse shortness of breath.” Well, neither do I, actually. I think it is rather awful to feel short of breath and I certainly would not support it in myself or anyone else.

I am aware that an alternative online dictionary has recently added a medical definition of endorse in to mean “to report a symptom.” Perhaps it should feel like an honor that the medical profession has convinced the Merriam-Webster company to amend and update a centuries-old term to conform to our new documentation convention. For whatever reason, though, that’s a feeling I just do not share.

You may be wondering how this practice evolved. I must admit that I do not know for certain. My deep dive into the blogs and reddit threads leads me to believe that it emerged as an alternative for the term complain, a term that we understand perfectly well in medicine, but which has very negative connotations for many patients. While some patients do actually complain and may appropriately be described as having a chief complaint (or, as is sometimes the case, a litany of complaints), many find this term offensive and prefer it not describe their chief concern or symptom.

To avoid all of this, it may be more appropriate to use more objective, non-value laden language such as reports, states, or describes. For instance, “the patient reports having one week of chest pain and describes an intermittent pressure sensation on the left chest that does not radiate. She states there is no shortness of breath, nausea, vomiting, or diaphoresis.” This covers all the bases without the ambiguity.

Now that that’s settled, let’s move onto my second least favorite term in the chart: denies.

I think the term denies has more legitimate applicability in our day-to-day medical parlance, but is still, in my opinion, often inappropriately used. According to the OED, deny means to declare untrue or nonexistent, repudiate, contradict, or to refuse a person or thing. At times this may appropriately describe a patient’s response. Consider the patient who states they were not drinking alcohol, but whose BAC is 0.35%. That patient is truly denying their use of alcohol – refusing to acknowledge the truth. But a patient stating that their chest does not hurt is not denying the presence of chest pain if it really is not there. Instead, they are indicating, reporting, or stating that they have no chest pain. To state they deny their pain is to imply they have been accused of having pain in the first place and either repudiate that claim, or declare its non-existence. It may technically be true, but likely only applicable to a handful of patients. I saw this much more when we were documenting a page full of negative ROS – “denies chest pain, headache, dysuria, etc.,” but it still seems to be dominating the negative symptom vernacular.

If you are still reading this, good for you! I endorse your decision to deny yourself an extra five minutes of doing something else with your time today. But in all seriousness, I think there is merit in using precise language in our medical documentation. As I have already indicated, we in the healthcare professions understand the way these terms are used and can draw conclusions based on their incorporation into the medical records. However, with expanded access to medical records, our patients are more readily able to review these documents than ever before. They may be relieved to know they are no longer considered “complainers,” but may be equally troubled or confused by the unique use of the terms “endorse” and “deny” in our contemporary medical documentation. It seems to me we could simply substitute the other terms I have already suggested without any difficulty, and create more simple, objective, accurate narratives of our patients’ ED encounters that patients and healthcare workers alike can mutually appreciate and comprehend.

If you are still not convinced, feel free to pull me aside during this summer’s Scientific Assembly at the Sagamore so we can continue the conversation further. I promise I won’t deny you the chance to endorse your choice of terminology in the medical record!