You may be surprised to find inaccurate information or unexpected language, tone, or even innuendo in your medical records. Was your past medical history truly "unremarkable"? Did you truly "deny" drinking alcohol? Did the note describe you as "unreliable"?
Here's how to decode unfamiliar jargon, comprehend some unexpected descriptors, and flag any mistakes you discover.
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What is included in a medical note?
A standard medical note contains several sections. These include:
* A description of the patient's current symptoms
* Past medical problems
* A list of medications taken
* Family medical history
* Social habits, such as smoking, drinking alcohol, or drug use
* Details of the physical examination
* Test results
* A discussion of the overall picture, along with recommendations for further evaluation or treatment.
Notes for new patients or annual exams are often more comprehensive. Follow-up notes may not include all of these points.
What may be confusing about medical notes?
Medical notes are not usually written in plain language because they are not primarily intended for a lay audience. As a result, you're likely to come across:
Medical jargon: You had an upset stomach and a fever. Doctors may say "dyspepsia" (upset stomach) and "febrile" (fever).
A standard medical note contains several sections. These include:
* A description of the patient's current symptoms
* Past medical problems
* A list of medications taken
* Family medical history
* Social habits, such as smoking, drinking alcohol, or drug use
* Details of the physical examination
* Test results
* A discussion of the overall picture, along with recommendations for further evaluation or treatment.
Notes for new patients or annual exams are often more comprehensive. Follow-up notes may not include all of these points.
What may be confusing about medical notes?
Medical notes are not usually written in plain language because they are not primarily intended for a lay audience. As a result, you're likely to come across:
Medical jargon: You had an upset stomach and a fever. Doctors may say "dyspepsia" (upset stomach) and "febrile" (fever).
Complex disease names: Have you ever heard of "multicentric reticulohistiocytosis" or "progressive multifocal leukoencephalopathy?" These are just two of many examples.
The use of common language in unusual ways: For example, your medical history may be described as "unremarkable" and test results as "within normal limits" rather than "normal."
Abbreviations: You might see "VSS" and "RRR," which stand for "vital signs stable" and "regular rate and rhythm," respectively.
If you are having trouble understanding a note, your health issues, tests, or recommendations, contact your doctor's office for clarification. The more you are informed about your health and your treatment options, the better.
What if a medical note is incorrect?
It is not uncommon for medical notes to contain minor errors. For example, it is possible that you had your tonsils removed 30 years ago, not 10 years ago. However, there may also be more serious errors. For instance, stating that arthritis in your left knee is severe when it is actually your right knee that is severe could lead to having x-rays (or even surgery!) performed on the wrong side. Additionally, failing to properly record a family history of cancer or heart disease could result in missing out on important screening tests or preventive treatments.
In an era of ever-increasing time constraints, the use of voice recognition software, electronic record templates, drop-down menus, and the ability to copy and paste text has made it easier than ever for healthcare providers to make (and perpetuate) errors in the medical record.
If you do notice a significant error that could have an impact on your health, request that your provider amend it.
What if the language in a medical note seems offensive?
Numerous studies have highlighted the problem of stigmatizing language in medical notes that can leave people feeling judged or offended. Negative attitudes can have a negative impact on the quality of our health care and willingness to seek care, and can also exacerbate health disparities. One study linked stigmatizing language to higher rates of medical errors. Of note, this study found higher rates of stigmatizing language and medical error among black patients.
Here are some examples:
Depersonalization: A note might describe a patient as "a drug abusing addict" rather than a person struggling with drug addiction.
Insulting or inappropriate descriptors: Notes might contain subjective descriptions that paint the patient in an unflattering light without providing context. For example, the note might say "the patient is unkempt and is drug-seeking" rather than "the patient is experiencing homelessness and has severe, chronic pain." If a person's recall of medical events from the past is hazy, they may be called "unreliable."
Dismissiveness: A medical note may suggest a symptom is not real or is exaggerated, rather than taking the complaint seriously.
An untrusting tone: Language such as "she claims she never drinks" or "he denies alcohol use" may suggest mistrust by the physician.
Why might this occur, you may wonder?
How does such language find its way into medical records? (To be clear, these potential explanations are not justifications.)
Tradition and training: Medical trainees, like other learners, tend to follow the lead of their mentors. So if a professor uses stigmatizing language, trainees may do the same.
Time pressure: With medical documentation (as in most everything else), mistakes are more common if you're in a hurry.
Bias: Like everyone else, doctors have biases, including ones they aren't conscious of. How we are taught to think about people — by family, by society — can seep into every area of life, including work.
Frustration: Doctors may feel frustrated by patients who do not follow their recommendations. That frustration can be expressed in their medical notes. For example, a note may say, "As expected, the patient's blood sugar is high; he is still not checking his blood sugar or following the diet recommended by his nutritionist."If the language in a note is confusing or bothersome, ask about it. The Open Notes movement and federal legislation have given most of us much better access to our medical records. This has worthy goals — greater transparency and better communication with people about their medical care — and unintended consequences.
Is changing the language in notes that healthcare professionals once shared primarily with each other a positive development? Generally speaking, yes. However, some physicians are concerned that notes will become less detailed, accurate, or useful if they omit information that could upset a patient.
I encourage you to read your healthcare providers' notes about your care. If there is a significant error or something you find confusing or objectionable, bring it up. Keep in mind that a signed medical note cannot usually be changed. However, your doctor can make clarifications or correct mistakes in an addendum at the end of the note.
As more and more patients read their medical notes, it is likely that healthcare professionals will be more thoughtful about the language they use. As a result, broad access to medical notes may improve not only people's understanding of their health, but also the quality of notes over time.
It's importnant to remember that the medical note is not the most crucial thing that occurs during a visit to your doctor. A great note does not always equate to excellent care, and vice versa. Still, your medical notes can be a valuable source of health information that is distinct from all others, including reputable health websites and social media: they are written by your doctor and they are all about you.
