Let’s say you request your doctor’s notes from a recent visit, and in it, you see terms like “imp,” “po,” “F/U” and “OD.”
Feeling insulted? Don’t be. These terms are shorthand for medical terminology: impression, par os (Latin for “by mouth”), follow up, and oculus dexter (Latin for “right eye”).
More transparency in health care is a good thing, but — like all big changes — it comes with some growing pains. Researchers at the University of Washington and Harvard Medical School advise doctors to use supportive language when making notes (“false positive” instead of “false alarm,” for example) and reduce medical jargon that could seem judgmental to a patient.
It also behooves patients to do some research to understand what the notes are saying.
The transmission of medical notes and records is becoming more widespread because of the use of electronic health records (EHR). You may have noticed your health practitioner is typing notes into a laptop or desktop computer during your visit, rather than writing in a paper chart. Which, if you believe in the old saw about doctors’ terrible handwriting, is a step forward.
In some practices and hospitals, a medical scribe might accompany a doctor with a rolling computer stand, taking on the clerical responsibilities of EHR and helping to gather and record patient information.
Perhaps because of some of the terminology, many doctors still aren’t comfortable in giving patients access to their notes. But under HIPAA, or the Health Insurance Portability and Accountability Act, you are entitled to your medical records. As of April 2021, most providers are required by law to make them available electronically, such as through secure internet patient portals. You can still request paper copies, of course.
Should we be requesting doctor’s notes after every visit? Yes, I believe we should. Research has shown there are several benefits to being able to review your doctor’s notes. Studies show that most patients remember less than half of what they discuss with their medical professionals. Reviewing the notes helps ensure you haven’t missed important information and that you and your medical team are on the same page. And the more connected you are with your medical team, the more you are able to manage your own health and well-being.
A nationwide nonprofit organization, OpenNotes (www.opennotes.org), seeks to make it easier for patients to access their notes and encourages doctors to share them. It was started in 2009 by health professionals at Beth Israel Deaconess Medical Center and Harvard Medical School, and it is supported by philanthropy and research grants.
According to OpenNotes, other benefits of reviewing your doctor’s notes and medical records include:
• The ability to ask better questions and make more confident decisions.
• More effective sharing of medical information with family members, other care partners, or new doctors.
• Better communication and partnership with caregivers of elderly parents and children.
• More trust between patients and their medical caregivers.
• The opportunity to identify mistakes and make sure records are accurate.
OpenNotes partnered in September with a company called Ciitizen (www.ciitizen.com), a free service for patients that helps them get the most out of their medical records. Their project, “Where Is My Medical Record?” (www.whereismymedicalrecord.org), is a web-based resource to help patients access their doctors’ notes and medical records.
The website helps explain “the complicated process of requesting records and offers step-by-step guidance about what constitutes medical record information blocking,” said Catherine DesRoches, executive director of OpenNotes and an associate professor of medicine at Harvard. Patient advocates, who are experts at navigating the health care system, can also help you access records.
What can you do? If your doctor’s practice or hospital has an electronic patient portal, learn to use it. At a visit, don’t hesitate to ask your doctor to turn the computer screen toward you to share what’s being written. Some doctors might even ask you to contribute to the notes before your appointment by, for example, listing your concerns in order of priority.
Afterward, when you review your doctor’s notes, ask for clarification on anything you don’t understand. And before you feel insulted by an unfamiliar term, look it up. You’ll find that S.O.B. doesn’t mean what you think — it stands for “short of breath.”
• Teri Dreher is a board-certified patient advocate. A critical care nurse for 30+ years, she is founder of NShore Patient Advocates (www.NorthShoreRN.com). She is offering a free, 30-minute phone consultation by calling (312) 788-2640 to make an appointment.