Do you ever read the notes written by your doctor or health practitioner during a medical visit? If not, you might want to check them out. Usually, these medical notes are full of helpful insights about your health and reminders of recommendations discussed. And there’s medicalese, of course: hard-to-pronounce illnesses, medications, and technical terms.
But you may be surprised to see incorrect information or unexpected language, tone, or even innuendo. Was your past medical history really that “unremarkable”? Did you actually “deny” drinking alcohol? Did the note describe you as “unreliable”?
Here’s how to decipher unfamiliar lingo, understand some surprising descriptions, and flag any errors you find.
What’s in a medical note?
A standard medical note has several sections. These include
- a description of current symptoms
- past medical problems
- a list of medications taken
- family medical history
- social habits such as smoking, drinking alcohol, or drug use
- details of the physical examination
- test results
- a discussion of the big picture, along with recommendations for further evaluation or treatment.
Notes tend to be more complete for a new patient or annual exam. Follow-up notes may not cover all of these points.
What’s potentially confusing about medical notes?
Most medical notes aren’t written using plain language because they aren’t intended primarily for a nonmedical audience. So it’s common to run across:
- Medical jargon: You had an upset stomach and a fever. Doctors may say “dyspepsia” (upset stomach) and “febrile” (fever).
- Complicated disease names: Ever heard of “multicentric reticulohistiocytosis” or “progressive multifocal leukoencephalopathy?” These are just two of thousands of examples.
- Use of common language in uncommon ways: For example, your medical history might be called “unremarkable” and test results called "within normal limits” rather than “normal.”
- Abbreviations: You might see “VSS” and “RRR,” meaning “vital signs stable” with a pulse that has a “regular rate and rhythm.”
If you’re having trouble deciphering a note or understanding your health issues, tests, and recommendations, check in with your doctor’s office for clarifications. The more you understand about your health and your options for care, the better.
What if a medical note is incorrect?
Minor errors in medical notes are not rare: maybe you had your tonsils removed 30 years ago, not 10 years ago. But there can be more important errors: stating that arthritis in your left knee is severe when it’s actually the right knee that’s severe could lead to having x-rays (or even surgery!) on the wrong side. And not properly recording a family history of cancer or heart disease could mean missing out on timely screening tests or preventive treatments.
In an era of ever-increasing time pressure, use of voice recognition software, electronic record templates, drop-down menus, and ability to copy and paste text, it’s easier than ever for health care providers to make (and perpetuate) errors in the medical record.
If you do see an important error that could affect your health, ask your provider to amend it.
What if the language in a medical note seems offensive?
Numerous studies have highlighted the problem of stigmatizing language in medical notes that can leave people feeling judged or offended. Negative attitudes can affect the quality of our health care and willingness to seek care, and can also widen health disparities. One study linked stigmatizing language to higher rates of medical errors. Of note, this study found higher rates of stigmatizing language and medical error among black patients.
Examples include:
- Depersonalization: A note might describe a patient as “a drug abusing addict” rather than a person struggling with drug addiction.
- Insulting or inappropriate descriptors: Notes might contain subjective descriptions that paint the patient in an unflattering light without providing context. For example, the note might say “the patient is unkempt and is drug-seeking” rather than “the patient is experiencing homelessness and has severe, chronic pain.” If a person’s recall of medical events from the past is hazy, they may be called “unreliable.”
- Dismissiveness: A medical note may suggest a symptom is not real or is exaggerated, rather than taking the complaint seriously.
- An untrusting tone: Language such as “she claims she never drinks” or “he denies alcohol use” may suggest mistrust by the physician.
Why might this happen, anyway?
How does such language make its way into medical notes? (To be clear, these possible explanations are not justifications.)
- Tradition and training: Medical trainees, like other learners, tend to follow the lead of their mentors. So if stigmatizing language is used by an instructor, trainees may do the same.
- Time pressure: With medical documentation (as in most everything else), mistakes are more common if you’re rushing.
- Bias: Like everyone else, doctors have biases, including ones they aren’t aware of. How we are taught to think about people — by family, by society — can spill over into every area of life, including work.
- Frustration: Doctors may feel frustrated by patients who don’t follow their recommendations. That frustration can be reflected in their medical notes. For example, a note may say, “As expected, the patient’s blood sugar is high; he is still not checking his blood sugar or following the diet recommended by his nutritionist.”
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 changing language in notes that health practitioners once shared mainly with each other a positive consequence? Mostly. Yet some doctors worry that notes will become less specific, accurate, or useful since they may leave out information that might upset a patient.
The bottom line
I encourage you to read your health providers’ notes about your care. If there is a substantial error or something you find confusing or objectionable, ask about it. By the way, a signed medical note cannot usually be revised. However, your doctor can make clarifications or correct mistakes in an addendum at the end of the note.
As more and more patients read their medical notes, it’s likely that health providers will be more conscientious about the language they use. So, wide access to medical notes may improve not only people’s understanding of their health, but also the quality of notes over time.
It's worth remembering that the medical note is not the most important thing that happens during a visit to your doctor. A great note isn’t the same as great care, and vice versa. Still, your medical notes can be a valuable source of health information that differs from all others, including trusted health sites and social media: they’re written by your doctor and they’re all about you.
About the Author
Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing
Dr. Robert H. Shmerling is the former clinical chief of the division of rheumatology at Beth Israel Deaconess Medical Center (BIDMC), and is a current member of the corresponding faculty in medicine at Harvard Medical School. … See Full Bio View all posts by Robert H. Shmerling, MD