Client or Patient? The Language We Use in Documentation

When I was working in an agency in 2009 an interesting shift started happening... the word "consumer" started to replace the word "client." And I really disliked it.

To be honest, I got a little self-righteous about it. "How dare we compare the service we provide to services in some store?" "I am not a consumer at my doctor's office!" "This is so offensive."

I refused to engage in the consumer terminology and kept my well-respected "client" in all my notes. And then one of my coworkers (a fabulous therapist, BTW) mentioned something to me in passing... "I don't understand why we don't use the client's name." 

Truthfully, this thought had never even occurred to me! Rather than writing "the client began to cry when talking about her mother" I could write "Julia began crying when talking about her mother."

Wow... do you notice the difference? It feels so much more personal! 

Hold up, Maelisa, these are legal documents. These are professional notes. Can I really do that?

The answer is yes, you can use whatever language you want!

Perhaps you're more traditional and prefer the word "patient." It conveys a certain professionalism, appropriate personal distance, and is very commonly used. (Side note: it also has the added benefit of easily and recognizably being abbreviated to "Pt" for those of you that prefer as little writing as possible)

Perhaps, like I did, you prefer the word "client." This also conveys an appropriate distance and reflection of the relationship while also valuing that therapy is different from other "medical" treatments. 

Perhaps *gasp* you actually prefer the word "consumer." Well, I can't blame you... our clients truly are consumers of a service. We are reminded of that every time issues arise with payment or dissatisfaction. 

Perhaps you prefer the word "member." This is common in insurance circles. While it may currently have a negative connotation for many, the idea behind being an active "member" is really quite noble. It conveys some investment in the service provided. 

Lastly, perhaps you prefer to use the person's name, like my friend and co-worker. That conveys a personal meaning to the notes and you know what, it gets the job done just as well as any other term we create for a sense of professional distance.

The actual phrasing doesn't really matter. What matters is the content, the meaning behind it, the story that unfolds note after note. 

I love when I review a client's file (for another therapist, not a client of my own) and I can picture exactly what it's like to be in the room with that person. I am able to read about their subtleties, personality and nuances. That's what matters.  

So, do what feels comfortable for you. Do what is meaningful to you. Write your client's story of treatment with you. And don't worry about it any more than that. 

What terminology do you use in your documentation and how come? Have you struggled with this topic? Leave a comment below. I'd love to hear about it!