In medical reports, neglect or improper use of professional vocabulary may indeed have a negative impact on diagnostic results. The following is a detailed analysis of the key causes and potential impacts： ### 1. **The necessity of accurate communication** -Standardization of terminology**: Medical terms (such as “myocardial infarction” instead of “heart attack”) can eliminate ambiguity and ensure that different medical professionals have the same understanding of the condition. For example, confusing “hematoma” with “bruise” may lead to a misjudgment of treatment priority. -**International norms**: Systems such as ICD (International Classification of Diseases) coding rely on specific terms. Incorrect use of words may lead to coding errors and affect insurance reimbursement or epidemiological statistics. ### 2. **Diagnose risk points in the chain** -**Imaging Journal Report**: If radiologists vaguely describe “nodules” as ”shadows", they may mislead clinicians into underestimating the risk of malignant tumors (such as during lung cancer screening). -**Laboratory data**: Simplifying “neutrophilosis” to “high white blood cells" may mask clues to sepsis or leukemia. -**Electronic medical record retrieval**: Non-standardized vocabulary will prevent key information from being retrieved by AI algorithms or follow-up doctors. ### 3. **Legal and ethical consequences** -**Medical disputes**: Statistics from the American Medical Association show that about 15% of misdiagnosis lawsuits are related to defective documentation. For example, misspelling “stroke” as “dizziness” may delay the thrombolytic treatment window. -**Cross-agency collaboration**: If “type 2 diabetes with nephropathy” is simplified to “diabetes" during referral, it may cause specialists to ignore renal function monitoring. ### 4. **Magnification of the impact of special scenes** -**Diagnosis of rare diseases**: If the characteristic of ”Mafan syndrome“ is described as ”long hands and feet", genetic testing may be delayed. -**Multilingual environment**: In the medical records of non-English patients, the wrong translation of “jaundice” (jaundice) as “yellow skin” may ignore the emergency treatment of biliary tract obstruction. ### 5. **Solution suggestion** -**Structured entry**: An electronic medical record system that adopts mandatory standardized fields (such as Smartphones in Epic). -**Clinical terminology support**: A real-time verification tool that integrates SNOMED CT or UMLS termbases. -**Multi-disciplinary verification**: Implement a “two-person verification” system for key documents such as pathology reports. **Conclusion**: The rigor of medical vocabulary is directly related to the quality of diagnosis and treatment. Research by Harvard Medical School has shown that standardized terminology use can reduce the misdiagnosis rate by 23%. It is recommended that medical institutions incorporate terminology specifications into the medical quality control system through technical tools and process design.