Clarity, Plain Language and Tone

A discharge sheet says ambulate as tolerated with assistance. The patient nods, goes home, and does not walk for four days. A policy sentence runs seventy-one words, and a supervisor reads it three times before deciding it probably means what she already does. A two-line email written to sound efficient lands as cold, and a colleague spends an afternoon rereading it. None of those writers was careless. All three produced sentences that were technically correct and functionally useless, because clarity is not a property of prose. It is an event that happens, or fails to happen, inside another head. This chapter takes clarity apart into parts you can operate: sentences built around a doer and a doing, words chosen for the reader rather than the writer’s standing, and tone calibrated so the message you sent is the message that arrives. You will free buried verbs, translate jargon without losing precision, refuse a request without losing a colleague, and run a five-pass revision in under ten minutes.

Section 1What clarity actually is

Clarity is a reader behavior, not a writer feeling

You cannot judge your own clarity from the inside, because you always already know what you meant. Reading your own draft, you are not decoding a sentence — you are recognizing one. The gap between recognition and decoding is where every clarity failure lives, and no amount of rereading closes it, since each reread makes you more fluent in your own text and less like the person you are writing for.

So the working definition has to be external. The plain language standard adopted by the International Plain Language Federation and published as ISO 24495-1 in 2023 puts it in a single sentence: a communication is in plain language if its wording, structure and design let the intended readers easily find what they need, understand what they find, and use that information. Three verbs. Find, understand, use. Notice what the definition does not say. It does not mention short words, and it does not mention grade levels. It also names design, which is why Chapter 4 is the other half of this one — a perfectly clear sentence on a wall of unbroken gray text is still unfindable.

Three verbs give you three separate failure modes, and they need different repairs. Writers who assume every complaint is a vocabulary problem tend to simplify words that were never the obstacle while leaving the actual obstacle untouched.

The third row is the one that catches experienced writers. “Promptly” feels responsible. It is an elastic word wearing the costume of a standard, and two reasonable people will stretch it to two different lengths — which is exactly the ambiguity a policy exists to remove. Chapter 7 makes this a rule for procedures. Here, treat it as a smell: any word that different readers could measure differently is a word that has not yet done its job.

What plain language is not

The most common objection to plain language is that it dumbs things down. It is worth taking seriously, because the objection is right about a real risk and wrong about the method. Plain language does not remove content, shrink nuance, or ban long words. It removes the friction between the content and the reader. A drug interaction is complicated; the sentence describing it does not have to be.

It is also not the same as informal. “We regret that your application was unsuccessful” and “hey, no luck on the application” differ in register, not clarity. Plain language is compatible with formal, legal and technical writing, and courts have generally treated plainly drafted contracts as fully enforceable. New York has required consumer contracts below a dollar threshold to be written in a clear and coherent manner using everyday words since 1978, and the United States Plain Writing Act of 2010 obliges federal agencies to write covered public documents plainly, with the Federal Plain Language Guidelines as the working manual. Whatever else plain language is, it is not legally naive.

Where scholars genuinely differ is on measurement. There is reasonably good evidence that plain-language revision improves comprehension and cuts the time readers need to complete a task, across settings from consent forms to tax notices. There is much weaker support for the idea that any single readability score predicts whether a particular document will work for a particular audience. Hold both findings at once: revise for plainness with confidence, and treat the number a tool gives you afterward with suspicion. Section 5 returns to this.

One worked example makes the point faster than the argument does. Here is a consent sentence in its natural habitat:

Prior to the commencement of the procedure, it is required that acknowledgement of the potential for adverse outcomes, including but not limited to bleeding, infection and the possible necessity of additional interventions, be documented by the patient or authorized representative.

Forty words, no human being in the subject slot, and a verb (“be documented”) that arrives thirty-two words in. Now the plain version, which loses nothing a lawyer would miss:

Before the procedure, you sign this form to confirm that we told you about the risks. Those risks include bleeding, infection, and the chance you may need another procedure.

Twenty-nine words, two sentences, and the reader is now the subject of a sentence about their own body. The risks are still enumerated. The legal function is intact. What disappeared was the fog.

Section 2The sentence engine: actor, action, order

Find the actor, find the action

English readers arrive at a sentence expecting a story shape: somebody does something. When the subject is a person or an organization and the main verb names what they did, comprehension is nearly free. When the subject is an abstraction and the verb is a placeholder, the reader has to reassemble the story before they can evaluate it, and they pay for that assembly out of the same attention budget you needed for your argument.

Take a sentence of the kind that fills institutional email: A determination regarding the eligibility of the applicant will be made by the committee following completion of the review process. Twenty words. Now ask the two diagnostic questions. Who does something? The committee. What do they do? They decide. Put those in the subject and verb slots and the sentence rebuilds itself: The committee decides whether you are eligible after it finishes the review. Twelve words, and it gained information — the reader is now “you” rather than “the applicant,” which is a person rather than a category.

The fastest diagnostic in this chapter is to underline the first real verb in a sentence you suspect. If it is a form of be, or one of the great placeholder verbs — occur, exist, take place, make, conduct, perform, provide, facilitate — then the real verb is almost always sitting nearby, wearing a noun costume.

Nominalizations: verbs in disguise

A nominalization is a verb or adjective turned into a noun: decide becomes decision, implement becomes implementation, fail becomes failure, able becomes ability. Watch for the suffixes: -tion, -ment, -ance, -ence, -ity, -ure, -al. Each one is a small act of freezing. The action stops being something someone does and becomes a thing that exists, at which point the sentence needs a second, weaker verb just to hold the frozen noun in place.

Nominalizations are not errors, which is why blanket bans backfire. They earn their keep in two situations. First, when the process itself is genuinely the topic: The investigation lasted six weeks is better than any version that unfreezes it. Second, when you need to point back at something you just said: This decision affects three units is a clean bridge between paragraphs. The problem is not their existence. It is their density, and their habit of appearing exactly where accountability should be.

Look at the last row twice. The rewrite is longer than the original, and it is enormously better. That is the honest version of concision: you are not chasing a word count, you are chasing the ratio of meaning to words. Cutting a reduction was observed freed the room that the actual numbers now occupy.

The same table demonstrates a companion habit. Sentences that open There is, There are, It is important that or It should be noted that use an expletive construction — a grammatically necessary placeholder subject that carries no meaning. Deleting the opener usually forces the real subject forward, which is why the fix improves the sentence twice: it deletes dead words and reveals who is responsible.

Passive voice: the honest account

You have probably been told to avoid the passive voice. That advice is half right and, as usually delivered, unhelpful. Passive voice is not an error and not a synonym for vague. It is a structural choice about which noun occupies the subject slot: the nurse gave the medication is active, the medication was given by the nurse is passive, and both are perfectly grammatical English. Linguists have complained for years that style guides not only over-prohibit the passive but frequently misidentify it, labeling any flat or evasive sentence “passive” whether or not it contains one. Learn the actual structure and you can make an actual decision.

The passive earns its place when the actor is genuinely unknown, genuinely irrelevant, or genuinely less important than the thing acted upon — and when keeping a consistent subject across several sentences helps the reader follow a thread. Method descriptions live here. So does much of epidemiology, and so do many honest statements of fact where naming a person would add heat without adding information.

It becomes a problem in one specific place: when the omitted actor is the point. The agentless passive — passive with the by phrase deleted — is the workhorse of institutional evasion, and incident writing, discipline and root-cause work are precisely the genres where readers are looking for the person. If a sentence describes something that went wrong and you cannot tell from the sentence who did it, ask yourself whether that was a stylistic choice or a flinch.

One idea per sentence, and length that varies

Readers hold a sentence’s subject in working memory until the verb arrives and tells them what to do with it. Every word you insert between the two is rent. This is why a 71-word policy sentence exhausts people who could read a 71-word paragraph without noticing: the paragraph resolves six times, and the sentence makes them wait.

Consider this, lightly disguised from a real staffing policy: In the event that a staff member is unable to report for a scheduled shift due to illness or other unforeseen circumstance, notification of the charge nurse or, in their absence, the house supervisor, must be provided not less than two hours prior to the commencement of the shift, except in circumstances where such notification is rendered impracticable, in which case notification shall be provided as soon as is reasonably practicable.

Now the same rule, unpacked into four sentences that each carry one idea: If you cannot work a scheduled shift, call the charge nurse at least two hours before it starts. If the charge nurse is unavailable, call the house supervisor. Both numbers are on the back of your badge. If something makes calling that early impossible, call as soon as you can and say why.

Seventy-one words became fifty-three, but the real gain is structural: four decisions, four sentences, in the order a person actually meets them. The rewrite also caught something the original hid. Nobody could have followed the old rule without knowing the phone numbers, and the old rule never gave them.

The corresponding failure is over-correction. A page of uniformly short sentences reads like a fire alarm and flattens every relationship between ideas, because the connective words — because, although, so, unless — are the first casualties. Aim for an average around fifteen to twenty words and let individual sentences vary widely around it. A short sentence lands hardest after a long one. That is the whole trick.

Section 3Choosing words your reader already owns

Inflated diction and the words that earn their place

Inflated wording is rarely vanity. It is usually anxiety — a belief that plain words will read as unserious, so the writer reaches for the version that sounds like an institution. The reader experiences the opposite of what was intended. Long Latinate phrasing signals distance, and distance in a workplace document reads as either evasion or indifference. Nobody has ever finished a memo thinking the writer must be highly qualified because they wrote at this point in time.

The swaps below are mechanical and you can run them with your eyes. Keep two cautions in mind. First, a swap is not a law; there are sentences where prior to is the right rhythm. Second, some of these words have narrow legitimate senses, and knowing them is what separates an editor from a search-and-replace macro.

Two related habits are worth naming. Intensifiers — very, really, extremely, quite, significantly in its loose sense — almost always mark a weak noun or verb the writer is trying to prop up. Very important wants to be critical, or better, a consequence: we cannot bill without it. And a hedge — somewhat, it appears that, may possibly — is either an honest signal of uncertainty or a shield, and you must know which you are doing. In clinical and scientific writing, hedging is a virtue: the findings are consistent with early pneumonia is more accurate than a claim of certainty you do not have. In a request to your manager, I was sort of hoping we might possibly consider is not accuracy. It is a request apologizing for having been made.

Jargon, terms of art, and abbreviations

Jargon is insider vocabulary used on an outsider. Note that the definition is relational, not lexical — no word is jargon on its own. NPO among nurses on a unit is fast, unambiguous professional shorthand; NPO on a sheet handed to a patient is a barrier. The same word is efficient inside the boundary and obstructive across it, and the only variable that changed was the reader.

A term of art is different. It is a word with a precise technical meaning that has no exact plain equivalent, so replacing it costs accuracy. Sepsis is not “a bad infection.” Informed consent is not “agreeing to it.” Negligence means something specific and legally consequential. You keep terms of art, and you gloss them once in ordinary words the first time they appear. The test is a single question: can I replace this word without losing precision? If yes, it was jargon and it goes. If no, it stays and gets a definition.

Abbreviations follow from the same logic. Spell the term out at first use with the abbreviation in parentheses, then use the short form. Do not invent abbreviations for your own convenience — an acronym that exists only in your document costs the reader more than it saves you. And in healthcare there is a hard constraint on top of the style rule: the Joint Commission maintains an official do-not-use list for abbreviations that have caused dosing errors, including U for units, IU, QD and QOD, trailing zeros such as 1.0 mg, and the abbreviated forms of morphine and magnesium sulfate. Those are not stylistic preferences. Chapter 13 treats them as documentation rules, which is what they are.

Writing for patients and the public

Health literacy in the general population is lower than most clinicians expect. The most-cited national survey of United States adults, conducted in 2003, found that only about one adult in eight scored at the highest proficiency level for health-related tasks, and that roughly a third scored at basic or below-basic. Whatever the precise figures today, the direction is stable and the practical implication is unambiguous: the average patient reading your instruction sheet is not a slow version of you. They are a competent adult meeting this vocabulary for the first time, usually while anxious, often tired, sometimes in pain.

A widely repeated guideline puts patient-facing materials at around a sixth to eighth grade reading level. Treat that as a useful rule of thumb rather than a validated threshold — it is a target that produces better documents, not a line where comprehension switches on. The moves that actually deliver it are concrete: lead with the action, address the reader as you, give numbers instead of frequency words, break compound instructions apart, and say what to do rather than what a category of thing is.

The last row is the discipline. Audience adaptation is not a blanket simplification policy applied to every sentence you write; it is a decision made per document, per reader. A clinician-to-clinician order should stay in the precise professional register, because that is where its precision lives. What must never happen is the reverse of either — technical shorthand handed to a patient, or a vague lay paraphrase entered into a chart where a colleague will act on it.

Then verify. Teach-back is the standard method and it costs about forty seconds: ask the person to explain the plan back to you in their own words. The framing carries most of the value. “Do you understand?” produces a yes from nearly everyone, because saying no is socially expensive. “I want to make sure I explained this clearly — can you tell me how you will take this medicine when you get home?” puts the burden on your explanation, where it belongs, and it routinely surfaces gaps that a nod concealed.

Section 4Tone: what the reader hears

Tone is inferred, not transmitted

Tone is the reader’s inference about your attitude toward them and toward the subject. You do not send tone. You send words, and the reader constructs an attitude from them plus everything else available — your history together, their day, the four other messages they opened first. That construction is not under your control. What is under your control is the size of the margin you leave for it.

There is a well-known experiment on this. In 2005, Justin Kruger and colleagues had people write messages intended as sarcastic or serious and predict how often recipients would identify the intent correctly. Senders were confident; recipients were close to chance. A related line of research has proposed that email carries a systematic drift — messages meant as positive arrive as neutral, and messages meant as neutral arrive as slightly negative. The exact size of that effect is still argued over, but the direction is consistent across studies and matches what anyone who has managed a team already suspects.

The operational consequence is simple and slightly uncomfortable: write one notch warmer than feels necessary. The message that feels neutral to you is landing as clipped. The one that feels almost excessively friendly is landing as normal. This is not about being nice. It is calibration — the same adjustment you would make if you knew your microphone ran two decibels quiet.

Register: a dial, not a switch

Register is the level of formality a relationship and a setting expect. Getting it wrong in either direction costs you. Too casual and you appear to have taken the reader lightly; too formal and you appear either anxious or cold, and you bury the ask under ceremony. Register is carried by small, countable signals: contractions, greetings, first names versus titles, sentence length, exclamation marks, emoji, hedging verbs, and how long it takes you to reach the point.

Two working rules cover most cases. Mirror the register of the most senior person in the thread, then move one notch more formal for anything that becomes a record. And remember that expectations vary — by organization, by profession, by seniority and by culture. How directly a request can be made without giving offense is genuinely different across cultures, and scholars disagree about how far any single model of politeness generalizes. The influential account by Brown and Levinson treats face-saving strategies as broadly universal; researchers working in Japanese, Chinese and other traditions have argued that it over-generalizes from English-speaking norms and understates social obligation. You do not need to settle that debate. You need to stop assuming that your own default is the neutral setting.

You-attitude, framing, and the courtesy that costs nothing

You-attitude means writing from the reader’s side of the desk — describing the situation in terms of what they experience, need and get, rather than what your department requires. “We require three business days notice for schedule changes” becomes “You can change a shift as long as you tell us three business days ahead.” Same policy, and the second version tells the reader what they can do instead of what the institution demands.

Positive framing does related work. State what is possible rather than only what is blocked. “We cannot process your request without the completed form” becomes “Send the completed form and we can process this the same day.” The constraint is unchanged; the sentence now contains a path forward. There is an ethical limit here and it matters: positive framing must never be used to obscure a refusal or soften a fact the reader needs. If the answer is no, the word no appears somewhere. Framing controls emphasis, not truth — the same line Chapter 1 drew for audience adaptation and Chapter 10 draws again for ethics.

Ordinary courtesy is cheap and effective: the person’s name, one clause acknowledging their situation, a concrete next step, and a way out if your proposal does not work. What is not effective is the collection of verbal tics that read as apology for existing — just, sorry to bother you, I hope this makes sense, if that makes sense. Apologize once, specifically, for the actual thing, then stop: “Sorry for the slow reply — I was off Friday” is complete. There is a real debate about whether advice to strip softeners falls unevenly on women and junior staff, whose directness tends to be judged more harshly. That criticism has force. The safest reading is that the goal is not fewer words of courtesy but fewer words of self-diminishment, which is a different edit.

Saying no, delivering bad news, and writing while angry

A refusal has a reliable shape: acknowledge, decide, explain, offer, leave the door open. Watch it work. Weak version: Unfortunately due to a variety of competing priorities at the present time it is not going to be possible for us to accommodate this request, though we will certainly keep it in mind going forward. That is thirty-five words that never say no, give no reason, and leave the reader unsure whether to ask again. Strong version: Thanks for putting this together — the case for the second scanner is solid. I cannot fund it this quarter; the capital budget is committed through September. Resubmit it in the October cycle and I will back it. If the wait creates a safety problem, tell me this week and I will escalate it separately. It refuses more clearly, explains, offers a route, and is warmer.

Whether to lead with bad news is one of the places where practitioners genuinely disagree. Traditional business-communication texts teach an indirect pattern — a neutral buffer, then the reasoning, then the decision — on the theory that a reader who meets the refusal cold stops reading. More recent practice, and the reading behavior described in Chapter 1, favors stating the decision early, because delay reads as evasion and readers hunt for the verdict anyway. A defensible middle: if the reader already expects a decision, lead with it. If the news is genuinely painful and personal, give one sentence of orientation so they know what is coming, then say it plainly in the second sentence. What never works is burying it in paragraph four and hoping the surrounding warmth absorbs it.

Finally, the anger protocol, because a single sent sentence can outlive a career’s worth of good work. Draft it somewhere that cannot send — a blank document, not the reply window. Wait overnight if the matter allows, and it usually allows more than it feels like it does. Then delete every sentence containing you always or you never, every adverb doing emotional work, and every diagnosis of another person’s character or motive. Ask the one question that survives all of this: what do I want to be different tomorrow? Write only the sentences that produce that. And recall from Chapter 1 that the message is retained, forwardable and potentially discoverable; the version of you that a stranger meets in an archive should be the version that was thinking.

Section 5The revision pass that makes it plain

Five passes, under ten minutes

Most people revise by rereading and fixing whatever catches their eye. That method finds typographical errors and misses structure, because the eye keeps landing in the same places. Named passes work better for a boring reason: a pass that is hunting for exactly one thing will find that thing, and you can run five narrow passes faster than one anxious general reread.

Pass 1, purpose. Can a stranger say what you want and by when after reading the first two lines? If not, move the ask up. This is Chapter 1 arriving as an edit rather than a plan. Pass 2, actors. Read only the subjects and main verbs. Where the subject is an abstraction or the verb is a placeholder, rebuild the sentence around a person and an action. Pass 3, cut. Run the inflated-phrase list, strip intensifiers, and delete any sentence that repeats a previous one in different clothes. Expect to lose twenty to thirty percent. Pass 4, words. For each technical term, ask whether it is jargon or a term of art for this specific reader; replace the first kind, define the second, expand every abbreviation on first use. Pass 5, tone. Read it aloud and listen for what a tired, slightly defensive reader could hear. Add one notch of warmth. Remove every trace of irony.

There is a sixth pass and it is not optional in professional contexts: verify names, numbers, dates, dosages, policy references and links. Clarity that is confidently wrong is worse than fog, since it gets acted on. Chapters 10 and 14 build that pass out properly.

Here is the whole routine on one paragraph. Before, at 95 words:

It has come to our attention that there have been a number of instances in which the completion of the incident reporting form has not occurred in a timely manner subsequent to the event in question. It should be noted that the timely submission of these forms is absolutely essential in order to facilitate the identification of trends and the implementation of appropriate corrective measures. Accordingly, all staff are reminded of the requirement that such forms be submitted in accordance with departmental policy, and questions regarding this matter may be directed to the appropriate supervisor.

After, at 70 words:

Nine incident reports last month were filed more than 72 hours after the event. Policy RM-08 gives you 24 hours. We need them inside that window because we review them weekly, and a late report means a hazard sits unfixed for another week. From 1 September, file within 24 hours using the Report Incident button in the chart. If you are unsure whether something qualifies, call me — over-reporting is fine.

Trace what each pass did. Pass 1 gave the reader an ask and a start date instead of a reminder. Pass 2 replaced it has come to our attention and completion has not occurred with a number and a real verb. Pass 3 removed it should be noted that, absolutely essential, in order to facilitate and in accordance with. Pass 4 replaced the vague in accordance with departmental policy with the actual reference, Policy RM-08, because a policy number is a precise term a reader may need to look up, and named the actual button. Pass 5 replaced all staff are reminded — which addresses everyone and therefore no one, in a tone of institutional disappointment — with you, a reason, and an open door. The second version is shorter, warmer, more specific and more demanding at the same time. That combination is what a good revision produces.

Readability formulas: useful, limited, easily gamed

Readability formulas such as Flesch Reading Ease, Flesch–Kincaid Grade Level, SMOG and Gunning Fog reduce a text to two measurements: average sentence length and average syllables or complex words per word. That is all. They are decades old, they were built to sort large collections of text, and they know nothing about your reader.

What they cannot see is most of what matters. They cannot tell whether the reader knows the words, whether the sentences are in a sensible order, whether the design lets anyone find the deadline, or whether the content is true. They are also trivially gamed: split one sentence into two and the score improves without a single idea becoming clearer. The classic demonstration is a sentence like the lesion is benign — four short words, a Flesch–Kincaid grade of roughly four, and completely opaque to the patient who most needs it. The lump is not cancer scores at least as well and is the version that actually communicates. The formula cannot separate them, because word familiarity is invisible to it.

Use them as a smoke alarm, not a thermostat. A patient handout scoring at a college reading level is telling you something real, and you should go look. A document scoring at grade six has proved only that the sentences are short and the words have few syllables. It has not proved that anyone understood it, and treating the score as the goal is how organizations produce documents that pass an audit and fail a reader.

Testing with one real reader

The cheapest usability test in existence takes four minutes and one person from your actual audience. Hand them the draft, then ask three things. What are you being asked to do, and by when? Find me the phone number. Say that second sentence back to me in your own words. Time it silently while they look.

You will learn more from watching where they hesitate than from anything they say afterward, which is why the timing matters more than the verdict. People are polite about documents and honest with their eyes. If they scroll back up, something is out of order. If they read a sentence twice, that sentence is broken regardless of how good it looks to you. Two or three readers catch the large majority of real problems; you do not need a laboratory, an instrument, or permission.

In clinical settings this same instinct is formalized as teach-back, and the logic transfers cleanly to any high-stakes document: never accept “that makes sense” as evidence of comprehension, because the social cost of admitting confusion is high and the person will pay it by staying quiet. Ask them to do something with the information instead. Comprehension shows up in performance, not in agreement.

The clarity rubric

Run this before sending anything that matters. It is deliberately behavioral — every row can be checked by looking at the page rather than by consulting your feelings about it.

Words worth knowing