How can bias appear in PT documentation, and how can it be avoided?

• A. Language that labels or stereotypes; avoid by using neutral, person-first language and objective descriptions of function.
• B. Use colorful adjectives to describe appearance.
• C. Use only medical jargon to describe patients.
• D. Write in first-person voice to express empathy.

Answer: (B)

Bias in PT documentation shows up when language labels or stereotypes about a person based on age, appearance, disability, or other characteristics creep in, rather than describing what the person can do and what matters to them. The way to avoid this is to use neutral, person-first language and to report function and participation objectively.

Describe the person by who they are and what they can do, not by judgments or assumptions. For example, say “a 68-year-old woman who ambulates with a cane and requires supervision for transfers” rather than phrases that imply a stereotype. Support your notes with objective measures of function—gait speed, range of motion, strength, activity limitations, and participation goals—and document progress toward those goals. Include factors that influence performance, such as pain level, fatigue, and support systems, without labeling the person in a biased way. This approach keeps the focus on observable, measurable information and the patient’s goals, which supports clear communication among providers and ethical practice.

Other approaches that rely on colorful descriptions of appearance, heavy use of jargon, or shifting to a first-person voice can introduce subjectivity, reduce clarity, or diverge from standard clinical documentation practices. Those approaches don’t contribute to unbiased, patient-centered notes the way neutral, function-focused language does.