Have you ever reviewed the notes your physician or other healthcare provider made during a visit ? If not, you might consider looking them up. These medical notes typically contain important information about your health as well as reminders of previously mentioned advice. Naturally there is medicalese which consists of difficult-to-pronounce diseases, prescriptions, and technical words.
Irregular information or unexpected phrasing, tone, or even innuendo, however, might surprise you. Were the medical records from your past truly that “unremarkable”? Did you truly “deny” having a drink? Did the note label you as”untrustworthy”?
Here’s how to interpret some strange terminology, comprehend some unexpected descriptions, and highlight any mistakes you come across.
What’s in a medical note?
There are various sections in a typical medical note. Among them are
- an explanation of the symptoms as they exist now
- prior health issues
- a record of prescription drugs consumed; family medical history; and social behaviors including drug usage, alcohol consumption, and smoking
- specifics of the physical examination, test findings, a summary of the situation, and suggestions for additional assessment or care.
For an annual exam or a new patient, notes are typically more thorough. Notes in follow-up may not address every one of these topics.
What’s potentially confusing about medical notes?
Since most medical notes aren’t meant for non-medical audiences, they’re not typically written in plain language. Thus, it’s typical to encounter:
- Medical terminology: You experienced fever and unsettled stomach. Physicians may use the terms “febrile” (fever) and “dyspepsia” (upset stomach).
- Complex names for diseases: Have you heard of “progressive multifocal leukoencephalopathy” or “multicentric reticulohistiocytosis”? There are countless of examples, these two included.
- Common language used in unusual contexts: For instance, rather of being described as “normal,” your test results may be described as “within normal limits” and your medical history as “unremarkable.”
- Shortcuts: It’s possible to see “VSS” and “RRR,” which stand for “vital signs stable” and “regular rate and rhythm” in the pulse.
- See your doctor office for clarifications if you’re experiencing problems reading a note or comprehending your health issues, tests, and suggestions. It is best if you are as informed as possible about your health and available treatment options.
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Errors in medical records are not uncommon; for example, you may have had your tonsils removed thirty years ago instead of ten. However, more significant mistakes can occur: declaring that you have severe arthritis in your left knee when, in fact, it is in your right knee could result in x-rays or even surgery being performed on the incorrect side. Additionally failing to accurately document a family history of heart disease or cancer may result in a delay in receiving early screening exams or preventative care.
With the advent of speech recognition software, computerized record templates, drop-down menus, copy-and-paste text, and ever-increasing time constraints, health care practitioners can now more easily produce and repeat mistakes in the medical record.
Ask your provider to change it if you find a significant mistake that might have an impact on your health.
What if the language in a medical note seems offensive ?
What if a medical note is incorrect?
Several studies have brought attention to the issue of stigmatizing language in medical notes, which can cause individuals to feel offended or criticized. A negative outlook can exacerbate health inequities and have an impact on the standard of our medical care as well as our willingness to seek it out. One study found a correlation between stigmatizing words and increased medical mistake rates. Notably, this study discovered that black patients experienced greater rates of medical errors and stigmatizing words.
As examples, consider:
- Depersonalization: Rather than describing a patient as someone who is battling drug addiction, a note can refer to them as “a drug abusing junkie.”
- Inappropriate or insulting descriptors: Notes may include subjective descriptions that unfairly characterize the patient without offering any background information. Instead of saying “the patient is facing homelessness and has significant, chronic pain,” the letter might read something like “the patient is untidy and is drug-seeking.” A person may be labeled as”unreliable”if their memory of past medical incidents is vague.
- Dismissiveness : Rather than treating the complaint seriously, a medical note might imply that a symptom is exaggerated or unreal.
- A tone of distrust: Phrases like “he denies alcohol use” or “she claims she never drinks” could imply that the doctor is not trusting the patient.
Why might this happen anyway ?
- How does wording like this find its way into medical records? (To be clear, they are not arguments; they are just possible explanations.)
- Tradition and education: Medical students have a tendency to emulate their mentors, just like any other students. Thus, if a teacher uses stigmatizing language, students might follow suit.
- Time constraints: Errors are more likely to occur when hurrying when it comes to medical documentation, just like they do with most other tasks.
- Bias: Physicians are human beings with prejudices, even if they aren’t conscious of them. The way our families and society instill in us the value of people may permeate all aspect of life, including the workplace.
- Frustration: Patients who disregard their advice might cause doctors to get frustrated. Their medical records show that they are frustrated.
- A note might read, “As expected, the patient’s blood sugar is high; he is still not testing his blood sugar or according to his nutritionist’s advised diet,” for instance.
- 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 it a good thing when medical professionals reword notes they used to mostly share with one another? Most of the time. However, some medical professionals are concerned that because notes can omit information that could offend a patient, they will become less precise, accurate, or helpful.
The bottom line
I recommend that you go over the notes your healthcare providers have made about you. Ask questions if you think something is unclear or offensive, or if there is a significant mistake. Revisions to a signed medical note are typically not possible. However, in an addendum at the conclusion of the message, your doctor can clarify anything or fix any errors.
Health care professionals will probably become more mindful of the wording they use as more patients view their medical records. Thus broad access to medical records may eventually enhance both the quality of the records and people comprehension of their health.
It’s crucial to keep in mind that during a doctor’s appointment, more happens than just signing a medical note. fantastic care and a fantastic note are not the same thing. Nevertheless, since your medical notes are penned by your doctor and are entirely focused on you, they can be a priceless source of health information that sets them apart from all other sources, including social media and reliable health websites.
Note:Never take the place of direct medical advice from your physician or any licensed healthcare provider.
As a seasoned content writer specialized in the fitness and health niche, Arun Bhagat has always wanted to promote wellness. After gaining proper certification as a gym trainer with in-depth knowledge of virtually all the information related to it, he exercised his flair for writing interesting, informative content to advise readers on their healthier lifestyle. His topics range from workout routines, nutrition, and mental health to strategies on how to be more fit in general. His writing is informative but inspiring for people to achieve their wellness goals as well. Arun is committed to equipping those he reaches with the insights and knowledge gained through fitness.