I don't think anyone should get bent out of shape for the use of the term "denies". It is just medical - speak. And for the record, the correct way to document that a patient has not had TB is to also write "Pt denies history of TB." It is also appropriate to write "Pt reports no history of STD." or "Pt states "I have never had an STD." " It doesn't mean that you don't believe him. It is the legally correct way of documentation. Documentation gets totally torn apart in a court of law, and it is very important that *all* practitioners, whereever their location, whatever their specialty, use the same language. If everyone had their own abbreviations and ways of writing, it would be very difficult to transfer records and read another practitioners notes.
The use of the word "denies" or the terms "Pt reports" and "Pt states" is also appropriate in the style of expected documentation. You are supposed to at least attempt to document objectively, not your opinion. If I document "Pt is resting comfortably" how do I infact know that is the case? Maybe my patient has just passed out in pain. And it doesn't tell the next practitioner who reads the chart anything. Instead, a more appropriate way of charting would be something like "Pt appears to be sleeping; lying quietly in bed, eyes closed, room is dimmed. Respirs are even and nonlabored." If I document "Pt has pain with walking" how do I know that, really? And how helpful is that to others who are caring for the person? Appropriate documentation would be "Pt grimaces and moans when ambulating. When asked, pt reports pain in her left foot and ankle, rates pain 8 on scale of 10."
If I wrote on a chart "Pt has no STDs" I am stating that I know for a fact that she has no STDs. How do I know that? Because she told me? How does *she* know that? Has she ever been tested? Does she even know what STDs are? I have had several women tell me they have never had any STDs, and then later, when I look in their chart to get their pap history (required for the lab requisition), I see that they have had HPV. HPV is an STD. So, if I would have documented they had no STDs, I would have been incorrect. People forget about a diagnosis, or they don't realize that certain infections are considered an STD, and sometimes they are embaressed to report it. I myself remember completely denying any history of surgery, only to have my doctor say, "What is this?" when he saw the scar that runs across ten inches of my abdomen from a surgery I had as an infant. It just totally slipped my mind. That happens. By saying "Pt denies STDs" or "Pt states no history of STDs" I am reporting what is happening. That she said she didn't have any STDs. Not that she doesn't have them, because I cannot possibly know that. Rather, I am writing what the fact is; that she says she doesn't have an STD.
The use of "denies" is not perjorative. It is simply appropriate documentation.