In medical reports, ignoring or misusing professional vocabulary may indeed have a negative impact on diagnostic results, treatment decisions, and follow-up medical processes, which are specifically reflected in the following aspects： ### 1. **Decreased diagnostic accuracy** -**Precision of terminology**: Medical vocabulary (such as “myocardial infarction” and "chest pain”) has a clear pathological definition. The use of vague or non-professional vocabulary may lead to a deviation in the doctor's judgment of the condition. -**Distortion of information transmission**: For example, “Hematuria” is divided into “naked eye hematuria” and “microscopic hematuria”. If it is only described as “blood in urine”, key details (such as bleeding volume or concomitant symptoms) may be missed, delaying the diagnosis of kidney disease or tumors of the urinary system. ### 2. **Barriers to interdisciplinary collaboration** -**Multi-disciplinary communication**: In complex cases, the radiology department describes that “grinding glass nodules” and ordinary "lung shadows” can cause different diagnosis and treatment paths (such as infection vs. Tumor). Terminology errors may cause surgical, oncology and other teams to formulate inappropriate treatment plans. -**Electronic medical record system dependence**: Standardized terms (such as SNOMED CT, LOINC) are the basis for AI-assisted diagnosis and data mining. The lack of terminology may affect the accuracy of automated warning systems (such as drug allergy reminders). ### 3. **Increased risk of treatment** -**Drug error**: Confusing ”heparin“ with ”insulin" and other drugs with similar pronunciation (LASA drugs) may lead to fatal errors. The standardized use of professional terms is an important line of defense for medical safety. -**Deviation of the surgical plan**: If “Papillary thyroid cancer” is mislabeled as “thyroid nodules”, it may lead to insufficient scope of surgery (such as lymph node dissection) and affect the prognosis. ### 4. **Legal and insurance disputes** -**Medical burden of proof**: In medical disputes, a clear diagnosis record of “acute ST-segment elevation myocardial infarction” is the key evidence to prove compliance with medical treatment norms, while non-professional expressions such as “heart attack” may weaken the effectiveness of proof. -**Insurance chargeback risk**: Medical insurance DRG/DIP payment relies on precise coding. For example, the coding of “community-acquired pneumonia” is different from that of “inhalation pneumonia”, and terminology errors may lead to chargebacks or expense write-downs. ### 5. **Scientific research and public health impact** -**Distortion of epidemiological data**: During the New Crown epidemic, distinguishing between "confirmed cases” and ”suspected cases" is essential for prevention and control strategies. Confusion of terminology may lead to resource mismatches (such as incorrect isolation scope). -**Clinical trial screening**: If the “HER2-positive breast cancer" in the entry criteria is incorrectly recorded, it may affect the scientific nature of the research results and the drug approval process. ### Coping strategy suggestions： 1. **Strengthen structured medical records**: Enforce the use of key terms through template entry (such as SOAP format). 2. **Doctor-patient communication skills**: Doctors can first explain in popular language, and then mark professional terms in medical records (such as“ "The patient complained of ‘palpitations’ [medical terminology: palpitations]"”. 3. **Termbase support tool**: Deploy a clinical decision support system (CDSS) to automatically prompt standardized terms and associated diagnostics. 4. **Continuing medical education**: Update terminology knowledge through CME courses (such as WHO's latest disease classification ICD-11). In short, medical professional terminology is the cornerstone of medical rigor. In the era of artificial intelligence and precision medicine, the standardized use of terminology is not only a clinical need, but also the core guarantee of patient safety.