Over the past few years, technology has allowed healthcare systems to open up your medical records to you.
Many good results will come from this new transparency, making patients more actively involved in their own healthcare. However, there is a basic disconnect that we need to explain to patients as this practice becomes more common. These documents written about you are not written to you.
Remember, medical schools do not teach doctors to chart for purposes of providing patients with a document, so that’s a fundamental challenge. In other words, if you are writing a document for the general public, you’re going to write it at roughly a 6th-grade reading level. Believe me, nothing in a medical record is written at a 6th-grade level. For one thing, it’s going to contain a lot of medical terminology, jargon and shorthand.
Also, the concept of transparency in healthcare is moving along at a fast clip. In fact, it’s moving much faster than the style and content of medical records in accommodating the patient reading them.
The problem for patients
What we find is that patients, although they are not trained in medicine, dig through their medical records with a fine-tooth comb. They search every last term on the Internet, even the most minor statements, usually without the proper frame of reference.
So, because they are not experienced in the delivery of healthcare, patients often come away absolutely terrified, magnifying any mention of an abnormality or disease in their record.
Tips for reading your patient record
If you choose to read your patient records, keep these points in mind:
- Expect inaccuracies and incomplete documentation. Doctors are always in a hurry, and documentation is a secondary priority in taking care of the patient. If you find inaccuracies that you feel may be dangerous for others to read, mention them to your doctor on the next visit.
- Remember: Most records are not letters to the patient. They are a way for the doctor to chart what he or she has thought or done. Records also serve as auditing and billing documents for the business of healthcare.
- You can’t judge the doctor on the grammar or flow of the document. Some of the best doctors have the most brief and concise chart documents. They may take better care of you than they take care of paperwork.
- The medical records are multiple-user documents. They often contain notes from nurses or other medical team members that have met with you. In electronic medical records, you are likely to encounter historical information that is pulled forward from visits that occurred months or years ago. You may encounter pages of old “boilerplate” information, or information that is collected only to meet audit or accreditation requirements.
- The most stress for patients reading their records is over lab tests, X-ray or MRI reports. Without medical training, they are nearly impossible to interpret rationally. Abnormal test results are very common, and are often harmless. Abnormal test results may actually be normal in individual situations – the lab does not know your medical background. X-ray and MRI results are the most frightening. The radiologist who reads the images will use specialized jargon and unusual language. Rare and deadly diseases may be mentioned as possible diagnoses. Seeing this in black and white can cause enormous anxiety for a patient. Doctors don’t treat x-ray reports, they treat patients. These images are only a tool to point us toward a clearer diagnosis, not a sentence and a verdict.
- Don’t be insulted by notations that seem personal, such as seeing a reference to your weight or the fact that you drink alcohol, smoke or that you’re depressed. Seeing it in writing is sometimes harsh, but these facts are relevant to understanding your physical condition and not made as personal judgments.
When you think about medical records, consider their purpose. For the last two centuries, when doctors wrote their notes, it was not to communicate to patients.
Patient records give doctors reminders of a patient’s health challenges. They record what symptoms you have experienced, and describe the treatment plan. This helps doctors recall details of each patient case and also helps communicate to other providers involved in a patient’s care. Keep this in mind as you begin to have greater access to these records.
