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 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:
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 here’s the translation:
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. 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. 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. 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.
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