ave you ever taken a peek at the notes your doctor or healthcare provider jots down during your visit? If you haven’t, you might want to start. These notes can be a treasure trove of insights about your health and a handy reminder of what was discussed. However, they’re often filled with medical jargon, complex terms, and sometimes even confusing or unexpected language.
You might find yourself puzzled by terms like “unremarkable” or “deny” and even surprised by how your medical history is described.
What’s Included in a Medical Note?
- A typical medical note includes several key sections:
- Current Symptoms: What you’re experiencing now.
- Past Medical Problems: Your health history.
- Medications: A list of what you’re currently taking.
- Family Medical History: Health issues prevalent in your family.
- Social Habits: Includes smoking, drinking, and drug use.
- Physical Examination Details: Observations from your exam.
- Test Results: Outcomes from any tests conducted.
- Recommendations: Suggestions for further evaluation or treatment.
New patient visits or annual exams usually have more comprehensive notes compared to follow-up visits.
What Can Be Confusing About Medical Notes?
Medical notes aren’t written in everyday language; they’re crafted for medical professionals. Here are some common issues you might encounter:
- Medical Jargon: Terms like “dyspepsia” (upset stomach) or “febrile” (fever) might be used instead of simpler language.
- Complex Disease Names: You might come across names like “multicentric reticulohistiocytosis,” which can be a mouthful.
- Uncommon Usage: Terms like “unremarkable” for a medical history might seem odd when it simply means “normal.”
- Abbreviations: Shortcuts like “SoB” (short of breath) and “RRR” (regular rate and rhythm) can be confusing.
If you’re unclear about any part of your notes, don’t hesitate to ask your doctor for clarification. Understanding your health and options for care is crucial.
What If There’s an Error in Your Medical Note?
Minor mistakes, like an outdated surgery date, are common. However, significant errors—such as documenting arthritis in the wrong knee—can lead to inappropriate treatments or missed screenings. Given the reliance on voice recognition software, templates, and copy-paste features, errors can easily slip through.
If you spot a major mistake, request an amendment from your provider. They can correct the record with an addendum.
What If the Language Feels Offensive?
Studies have shown that some medical notes contain stigmatizing or insensitive language, which can affect your care experience and potentially widen health disparities. Examples include:
- Depersonalization: Describing a patient as a “drug abusing addict” instead of acknowledging their struggle with addiction.
- Inappropriate Descriptors: Using terms like “unkempt” or “unreliable” without context.
- Dismissiveness: Minimizing symptoms or complaints.
- Untrusting Tone: Language that implies disbelief, such as “denies alcohol use.”
Why Does This Happen?
Several factors contribute to this issue:
- Tradition and Training: Medical trainees often mimic the language and attitudes of their mentors.
- Time Pressure: Rushed documentation can lead to mistakes and careless language.
- Bias: Unconscious biases can affect how patients are described.
The Bottom Line
Reading your medical notes can be enlightening and empowering. If you find errors or language that bothers you, bring it to your provider’s attention. Although a signed note generally cannot be altered, clarifications and corrections can be added.
As more patients review their medical notes, it’s likely that healthcare providers will become more conscientious about their language. While great notes are important, they’re just one part of your overall care. Your medical notes are a valuable resource, offering insights directly from your healthcare provider tailored specifically to you.
Source:
Shmerling RH. Ever read your medical record? Here’s why you should [Internet]. Harvard Health. 2024 [cited 2024 Jul 26]. Available from: https://www.health.harvard.edu/blog/ever-read-your-medical-record-heres-why-you-should-202407083056