In SOAP notes, which practice supports patient autonomy for naming and pronouns?

• A. Use clinician-preferred terms.
• B. Avoid using pronouns to prevent misgendering.
• C. Use the patient’s preferred name and pronouns as indicated by the patient; include pronunciation notes.
• D. Document gender identity only if provided.

Answer: (C)

Respecting a patient’s chosen name and pronouns in SOAP notes supports their autonomy and ensures accurate, respectful documentation. When you use the patient’s preferred name and pronouns, you acknowledge who they are and communicate that you value their identity, which strengthens trust and collaboration in care. Including pronunciation notes further promotes clear communication, especially for names that are unfamiliar or culturally diverse, helping all team members address the patient correctly and avoid embarrassment or distress.

Using clinician-preferred terms erases the patient’s self-identification and can create a barrier to honest history-taking and rapport. Avoiding pronouns altogether risks ambiguity and misgendering, which undermines respectful care. Documenting gender identity only if provided can miss important information needed for care and again implies it’s optional or out of scope. By consistently using the patient’s preferred name and pronouns and adding pronunciation guidance, the notes reflect the patient’s identity respectfully and support accurate, person-centered care.