Do you ever take a look at the notes your doctor or healthcare professional writes during a medical visit? If not, it's worth considering reviewing them. These medical notes are often packed with valuable information about your health and reminders of recommendations that were discussed. Medical jargon is a language that includes diseases, medications, and difficult-to-pronounce technical terms.
You may be surprised to find inaccurate information or unexpected language, tone, or even innuendo in your medical records. Was your past medical history really “normal”? Did you really “deny” drinking? Did the note describe you as “unreliable”?
Here's how to decode unfamiliar jargon, understand some unexpected descriptions, and point out any mistakes you discover.
CDC Photo
A standard medical note contains several sections, including:
* A description of the patient's current symptoms.
* Past medical problems
* A list of the medications you take
* Family medical history
* Social habits, such as smoking, drinking alcohol or using drugs.
* Physical examination details
* 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 can be confusing about medical notes?
Medical notes are not usually written in plain language because they are not primarily intended for a non-specialist audience. Therefore, you are likely to encounter:
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.
Using common language in unusual ways: for example, your medical history may be described as “unremarkable” and your test results as “within normal limits” rather than “normal.”
If you have trouble understanding a note, your health issues, tests, or recommendations, contact your doctor's office for clarification. The more informed you are about your health and treatment options, the better.
What happens if a medical note is incorrect?
It's not uncommon for medical records to contain minor errors. For example, you may have had your tonsils removed 30 years ago, not 10. However, there can be more serious errors, too. For example, indicating that arthritis in your left knee is severe when it's actually your right knee that's severe could result in you having X-rays (or even surgery) on the wrong side. Also, failing to properly record your family history of cancer or heart disease could result in missing important screening tests or preventative 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 notice a significant error that could affect your health, ask your provider to correct it.
What if the language in a medical note seems offensive?
Numerous studies have highlighted the problem of stigmatizing language in medical records, which can make people feel judged or offended. Negative attitudes can negatively impact 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. Notably, this study found higher rates of stigmatizing language and medical errors among Black patients.
Here are some examples:
Depersonalization: A note might describe a patient as “a drug addict” rather than a person struggling with drug addiction.
Offensive or inappropriate descriptions: Notes may contain subjective descriptions that portray the patient in an unflattering light without providing context. For example, the note may say “patient is disheveled and seeking drugs” instead of “patient is homeless and has severe chronic pain.” If a person’s recollections of past medical events are hazy, they may be considered “unreliable.”
Disdain: A doctor's note may suggest that a symptom is unreal or exaggerated, rather than taking the complaint seriously.
A distrustful tone: Language such as “she claims she never drinks” or “he denies drinking” may suggest distrust on the part of the doctor.
You might be wondering why this might happen.
Tradition and training: Medical trainees, like other students, tend to follow the example of their mentors. Therefore, if a teacher uses stigmatizing language, medical trainees may do the same.
Time pressure: With medical paperwork (as with almost everything else), mistakes are more common if you're in a hurry.
Biases: Like everyone, doctors have biases, even if they aren't aware of them. The way we're taught to think about people (by family, by society) can filter into all areas of life, including the workplace.
Is there a benefit to changing the language of notes that healthcare professionals once shared primarily with each other? Generally speaking, yes. However, some physicians are concerned that notes will become less detailed, accurate or useful if they omit information that might upset a patient.
I encourage you to read your doctor's notes about your medical care. If there is a major error or something that seems confusing or objectionable to you, please discuss it. Please note that a signed medical note generally cannot be changed. However, your doctor may be able to make clarifications or correct errors in an addendum at the end of the note.
As more patients read their medical records, health care professionals are likely to be more careful about the language they use. As a result, broad access to medical records can improve not only people's understanding of their health, but also the quality of medical records over time.
It's important to remember that the doctor's note isn't the most important thing that happens during a doctor's visit. A good note doesn't always equate to excellent care, and vice versa. Still, your doctor's notes can be a valuable source of health information that stands out from all the others, including reputable health websites and social media: they're written by your doctor and focused on you.
Recent Comments