| ||What Your Doctor Is Saying || |
Reading Your Medical Record
Last reviewed by Faculty of Harvard Medical School on January 13, 2011
By Robert H. Shmerling, M.D.
Beth Israel Deaconess Medical Center
In an ideal world, communication occurs in two directions you tell your doctor about your symptoms, your concerns, your efforts to maintain your health as well as you can, and so on. Your doctor answers your questions, tells you what he or she thinks is going on with your health, suggests remedies if any are needed, and recommends other ways to stay healthy. Each of you listens carefully to the other and maintains an open line of communication even after the office visit.
But in real life, some people might prefer to review their own medical records, thinking that it may be quicker or easier to understand what is going on. Probably not. Doctors often use structure, style and terminology that lets them pack a great deal of information into their notes.
Even putting aside the quality of the handwriting (and thankfully, many health care professionals are going to a computerized or other typed system), medical records tend to be particularly "user unfriendly" because their primary purpose is not to communicate with non-medical people. Communication in the record tends to be "medicalese" for your doctors' reference and for other medical professionals who are now (or may later be) involved in your care.
The Progress Note: A Primer
The document that records what goes on at your first doctor's visit is called an "initial note." Documents recording your subsequent visits are called "progress notes" because they reflect your progress since the prior visits. The initial note will be more detailed than a progress note and include categories such as past medical problems, medications, allergies, family history, social history (such as whether you are married or are employed), and a "review of systems" (a listing of symptoms that are present or absent in the various organs of the body).
The progress note begins with identifying information about the person. There is usually one sentence describing the age, gender, and "chief complaint" (the primary reason for the appointment). For example, the note may begin: "Ms. Jones is a 43 year-old woman with a chief complaint of abdominal pain." The remainder of the note typically follows a structure and order taught in many medical schools called the "SOAP" note, which stands for subjective, objective, assessment and plan:
- Subjective This refers to those things that are not tangible, that cannot necessarily be seen or touched or measured; it is a narrative of your symptoms, your experience (such as abdominal pain), rather than a "sign" or a finding (such as an enlarged liver during the abdominal examination). It describes the chief complaint in more detail, including how it started, any factors that make it better or worse, and how long it has been going on. A brief review of other ongoing medical problems and medication use may follow here, especially if it seems relevant to the chief complaint.
- Objective This section describes or lists the findings detected during the physical examination, starting with the "vital signs," including blood pressure, heart rate, breathing rate and/or temperature. If the chief complaint was abdominal pain, for example, the examination of the abdomen might follow and would describe whether there was pain (tenderness) in any particular area, or if it hurt more with pushing down on the abdomen (palpation) or letting go (rebound tenderness). If there is enlargement of the abdominal organs, including the liver (hepatomegaly) or spleen (splenomegaly) or if there is an abnormal lump or fullness (mass), they would be mentioned in this section. Depending on the particular situation, more or less detail about findings from other parts of the body would follow.
Another entry in the "objective" section is test results, and they are usually found just after the physical examination. Results of blood counts, blood sugar, tests of kidney and liver function, and urine analysis (if requested) are typical examples.
- Assessment (or Impression) At this point, the note will list or discuss the thinking of your doctor, how he or she puts together all the information that has come before into an overall impression. It is here that a "differential diagnosis" is noted, meaning that the multiple possible explanations are entertained to account for the overall picture, with comments about why each is more or less likely.
- Plan This is the action component of the note, the place where your doctor describes his or her recommendations, including tests, treatments, referrals to other health care professionals and plans for another appointment. It also may contain contingency plans, for example, what to do if symptoms get worse.
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How the Note Actually Appears
Even knowing about the organization of the "SOAP" progress note, it may still be very difficult to decipher, in large part because of the shorthand doctors use. For example, here's how the history and examination described above might actually appear in a progress note:
43 y/o ♀ w/RUQ pain, occ. rad. midepigastr., esp. ρ fatty foods; acute onset x 1 mo., wkly x 30', incr. freq. X 1 wk. θf/c/n/v/d. S/P appy, hx HTN rx'd w/HCTZ-25 mg, 1 po q.d. E: VSS/NI, afeb, θHSM, + pain w/palp. RUQ, θrebound Imp: ?gallstone, r/o PUD, hepatitis P: √ US, LFTs, CBC, avoid FFs, call if Sx worse/f/n/v, ph. f/u 2-3d, appt. 3wks.
And heres the translation:
The patient is a 43-year-old woman with abdominal pain in the right-upper abdomen, occasionally radiating to the mid upper abdomen, especially after eating fatty foods. It started rather abruptly about one month ago, occurring weekly, lasting 30 minutes, but it has become more frequent over the last week. There has been no associated fever, chills, nausea, vomiting or diarrhea; she has had an appendectomy, and has a history of hypertension treated with hydrochlorothiazide, 25 milligrams, one by mouth daily. On physical examination, vital signs are stable and normal; she does not have fever. Examination of the abdomen reveals normal size liver and spleen, but there is pain with pressure in right upper abdomen without pain when the pressure is quickly released. Impression: possible gallstone but cannot rule out peptic ulcer disease or hepatitis. Plan: check ultrasound, liver-function tests, complete blood count. Avoid fatty foods. Patient to call if symptoms worsen, or if fever, nausea, or vomiting develops. She will follow-up in two or three days by phone and the next appointment will be scheduled for three weeks.
In this example, an entire paragraph was reduced by about two-thirds using shorthand that most health care professionals will understand. Clearly, however, it comes at the expense of being unintelligible to most patients.
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Does it Really Have To Be This Way?
The answer is "probably not" but as long as the time pressure on health care professionals continues to rise, it is unlikely that office notes will become easier to read. There is hope, though. Increasingly, doctors are using dictation systems to transcribe notes from their spoken words to typed print; it is easier to read and tends to contain far less shorthand and medical jargon. In addition, many physicians are exploring ways of having patients enter symptoms themselves by checking them off an online form before their office visit. That form would become a part of the note for that visit. Other programs "translate" medical terminology into lay language, and online sites allow patients to review the notes from office visits and notify their health care professionals of any new or erroneous information. Another development on the horizon: voice recognition systems that enter spoken words directly into a computerized medical record.
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The Bottom Line
Don't expect to read your medical record as you would the morning paper. It may be better just to ask your questions in the office, on the phone or by e-mail. On the other hand, the day may come soon when it is not only easy to read your own medical record, but you may help create it. Until your doctor has more (rather than less) time to spend with you or has a way to efficiently create office notes that are easy to understand (as with voice recognition systems), that day will not be here anytime soon.
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Robert H. Shmerling, M.D. is associate physician at Beth Israel Deaconess Medical Center and associate professor at Harvard Medical School. He has been a practicing rheumatologist for over 20 years at Beth Israel Deaconess Medical Center. He is an active teacher in the Internal Medicine Residency Program, serving as the Robinson Firm Chief. He is also a teacher in the Rheumatology Fellowship Program.