Cognitive Bias and Linguistic Mechanisms in Clinical Records and Reports: Implications for Client Care
Cognitive Bias and Linguistic Mechanisms in Clinical Records and Reports: Implications for Client Care
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Issue Date
2025-08-15
Authors
Darby, Kim
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Abstract
Clinical documentation is an important element of client care. One of the purposes of clinical documentation is to record essential and relevant information to ensure continuity of care. Clinicians have a fiduciary responsibility to ensure the language they use in clinical communications respects the dignity of the client and is non-maleficent. As such, many organizations have made efforts to guide clinicians to use wording that is inclusive and free of stigma and bias. While many guiding documents produced by government and corporate organizations highlight stigmatizing language to avoid and provide alternatives which are considered to be more acceptable, none of these documents draw specific attention to the linguistic mechanisms which create and perpetuate implicit bias and stigmatization. Implied biases can impact how a client is perceived, what information is documented about them, and the quality-of-care they receive. It also impacts a client psychologically. Cognitive bias has been identified as one of the major causes for diagnostic errors in clinical settings. In this project, I examine the underlying mechanisms that contribute to cognitive bias and stereotypes, as well as how biases and stereotypes influence clinical documentation. I explore how linguistic mechanisms create and perpetuate stereotypes and reveal cognitive biases, as well as how it impacts the quality-of-care clients receive and what protective practices can be implemented to mitigate the negative impacts of cognitive bias on client care.
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Keywords
linguistic mechanisms , cognitive bias , linguistic bias , stereotypes , decision-making , dual-process theory , signal detection theory , stigmatization , language , heuristics , debias , stigma , violence